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College  of  ^ijpsicians  anb  ^urgeong 

Hibrarp 


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TRAUMATIC 

INJURIES   OF   THE   BRAIN 

AND    ITS   MEMBRANES 


IVITH  A   SPECIAL   STUDY  OF 

PISTOL-SHOT  iVOUNDS  OF   THE  HEAD 

IN    THEIR   MEDICO-LEGAL   AND 
SURGICAL   RELATIONS 


BY 

CHARLES   PHELPS,    M.  D. 

SURGEON    TO    BELLEVUE    AND    ST.    VINCENT's    HOSPITALS 


%,\ 


WITH    FORTY-NINE    ILLUSTRATIONS       A. 


NEW     YORK 

D.    APPLETON    AND    COMPANY 

1897 


Copyright,  iSgy, 
By   D.    APPLETON   AND   COMPANY. 


146 


PREFACE 


This  work  is  designed  to  be  a  concise  and  systematic 
exposition  of  the  injuries  which  the  brain  suffers  from 
external  violence,  a  division  of  brain  surgery  which  has 
th<5  greatest  practical  importance  and  has  received  the  least 
careful  attention.  It  is  believed  that  it  will  not  only  be 
of  interest  to  surgeons,  but  will  meet  the  requirements  of 
general  practitioners  in  whose  experience  such  injuries  are 
infrequent,  and  who  in  exceptional  instances  have  urgent 
need  of  the  aid  to  be  derived  from  a  wider  clinical  obser- 
vation than  their  own  opportunities  have  permitted.  It  has 
been  based  essentially,  if  not  exclusively,  upon  an  obser- 
vation of  five  hundred  consecutive  cases  of  recent  oc- 
currence. These  cases  are  so  large  in  number,  and  so  va- 
ried in  character,  and  in  so  many  instances  are  complete 
in  the  record  of  essential  historic  and  necroscopic  detail, 
as  in  themselves  to  afford  material  for  a  comprehensive 
history  of  intracranial  traumatism.  The  picture  they  rep- 
resent is  incomplete  only  in  the  illustration  of  secondary 
pyogenic  infection  involving  the  brain  substance.  In  view 
of  this  clinical  deficiency,  the  consideration  given  to  cere- 
bral abscess  has  been  supplemented  by  some  account  of  the 
conditions  of  septic  invasion  and  of  the  degenerative  proc- 
esses which  it  occasions,  abstracted,  by  permission  of  the 
distinguished  author,  from  Macewen's  "  History  of  the  Pyo- 
genic Inflammations  of  the  Brain  and  Spinal  Cord." 

The  generalizations  which  have  been  made,  and  the 
conclusions  which  have  been  reached,  from  clinical  obser- 
vation, have  been  verified  in  each  instance  by  necroscopic 
examination. 


jy  PREFACE. 


In  an  appended  series,  all  those  cases  in  which  necropsy 
was  had,  and  a  certain  number  of  others  which  terminated 
in  recovery  or  in  which  necropsy  was  otherwise  impracti- 
cable, have  been  collated.  This  course  has  permitted  the 
preservation  of  continuity  in  the  text  by  the  omission  of 
interpolated  illustrative  cases,  has  afforded  a  means  for  the 
disproval  of  possible  unwarranted  or  erroneous  deductions, 
and  has  preserved  much  material  for  the  use  of  indepen- 
dent observers  hereafter.  They  have  been  classified  sim- 
ply from  their  relation  to  cranial  fractures,  and  this,  though 
an  imperfect  method  of  classification,  is,  by  reason  of  the 
multiplicity  of  lesions  in  individual  cases,  the  only  one 
which  has  seemed  practicable. 

The  lesions  which  attend  pistol-shot  wounds  of  the  head 
have  been  considered  apart  from  general  injuries,  as  a 
method  more  clearly  presenting  their  distinctive  character- 
istics. Their  complete  history  has  necessitated  an  abstract 
of  the  results  of  a  series  of  cadaveric  experiments,  instituted 
to  determine  for  legal  purposes  the  extent  to  which  the 
conditions  under  which  they  have  been  inflicted  can  be 
predicated  from  the  appearances  they  present.  These 
observations  have  been  sufficiently  extensive  to  better 
define  not  only  the  positive  value,  but  the  limitations,  of 
medical  evidence  in  such  cases  than   has  been  heretofore 

possible. 

This  portion  of  the  work  which  directly  concerns 
medical  jurisprudence  is  especially  designed  for  the  use 
of  the  legal  profession  in  more  precisely  estimating  the 
proper  weight  to  be  given  to  expert  testimony  in  cases  of 
this  character. 

The  author  has  much  pleasure  in  acknowledging  his  in- 
debtedness to  his  colleagues  of  the  Fourth  Surgical  Divi- 
sion of  Bellevue  Hospital,  Dr.  Jno.  W.  S.  Gouley  and  Dr. 
Wm.  F.  Fluhrer,  and  of  the  Surgical  Service  of  St.  Vin- 
cent's Hospital,  Drs.  Stephen  Smith,  Frederick  S.  Dennis, 
and  Jos.  D.  Bryant,  through  whose  courtesy  his  oppor- 
tunities for  clinical    observation    have  been    greatly  ex- 


PREFACE.  V 

tended.  He  is  also  under  very  great  obligation  to  succes- 
sive house  staffs  of  the  same  hospitals,  and  to  the  medical 
officers  of  the  Coroner's  Office  during  the  past  six  years 
for  the  constant  aid  and  co-operation  which  have  made 
possible  the  collection  of  the  great  mass  of  facts  which  the 
nature  of  this  work  has  involved.  He  has  finally  to  make 
acknowledgment  of  the  skilled  marksmanship  and  other- 
wise valuable  assistance  rendered  to  him  bv  Drs.  J.  H. 
Titterington,  Henry  L.  Whitener,  and  Harry  L.  Hib- 
bard,  late  of  Bellevue  Hospital,  and  by  Drs.  John  Freeland 
and  Jno,  D.  Gorman,  in  the  difficult  and  laborious  task 
of  cadaveric  experimentation. 

34  West  Thirty-seventh  Street, 
July,  1897. 


TABLE  OF  CONTENTS. 


PART    I. 
General  Traumatic  Lesions. 

a  preliminary  consideration  of  cranial 
fracture. 

PAGE 

Classification  of  Injuries  of  the  Head,     .......  i 

Cranial  Fracture, 2 

Classification,     .         .         .         ........  2 

Fracture  of  the  Cranial  Base,            ........  3 

Direct  and  Indirect,           .........  4 

Mechanism,         . 6 

Complications  of  Cranial  Fracture, 11 

Symptomatology  and  Diagnosis, 12 

Fractures  of  the  Vault,      .........  12 

Fractures  of  the  Base,        .........  13 

External  Hemorrhages  of  Cranial  or  Intracranial  Origin  ;       .         .13 
their  Comparative  Frequency  in  Different  Forms  of  Basic  Frac- 
ture,   14 

their  Diagnostic  Value,      .         .         .         .         .         .         .         .         .  iS 

Escape  of  Brain  Matter,    .........  21 

Water}-  Discharges, 21 

CEdema  of  the  Mastoid  Region,        .......  23 

Implication  of  the  Cranial  Nerves,    ...;...  24 

Localized  Pain,           ..........  26 

Indirect  Symptoms  from  Intracranial  Complication,        .     '     .         .27 

Prognosis,         ............  28 

Concomitant  and  Consecutive  Complications,  .         .         .         .30 

Treatment, 32 

Shock,         ............  33 

Fracture  of  the  Base,         .........  33 

Fracture  of  the  Vault,        .........  34 

Incision,     ............  35 

Elevation  of  Depressed  Bone,            .......  36 

Trephination,     . .  39 


Vlll 


TABLE    OF   CONTENTS. 


CHAPTER    I. 


Pathology. 


Shock, 


ty, 


Exsanguination,   and  Diminu 
stic  Degeneration 


Fluid 


Direct  Lesions, 

Classification,    . 
Hemorrhages, 

Epidural,    . 

Pial 

Cortical,     . 

Dangers  of  Hemorrhages 
tion  of  Cranial  Capac 

Terminations  in  Absorption  and  Cy 
Thromboses  of  Dural  Sinuses, 
Contusion,         .... 
General  Contusion  of  the  Brain, 

Anatomical  Conditions,     . 

Duret's  Theory  of  Displacement  of  the  Cerebro-Spinal 

Concussion  and  Compression,  .... 

Prescott  Hewitt — Observations  of  Contusion, 

Von  Bergmann's  Theory  of  Concussion  and  Compression 

Structural  Alteration  Attends  All  Brain  Injuries, 
Limited  Contusion  of  the  Brain, 

Anatomical  Conditions, 
Contusion  of  the  Meninges. 

Hemorrhage,      .... 

Subarachnoid  Serous  Effusion, 
Laceration  of  the  Brain, 

Anatomical  Conditions,     . 

Terminations,    . 
Indirect  Lesions — Secondary  Inflammations, 

Due  to  Accidental  Infection  of  Primary  Lesions. 

External  or  Distant  Origin  of  Pathogenic  Germs 

Infrequency  of  Occurrence,       .... 

Macewen's  History  of  Intracranial  Infection, 

Acute  Leptomeningitis.     . 

Acute  Serous  Leptomeningitis, 

Purulent  Leptomeningitis. 

Red  Softening. 

White  Softening, 

Cerebral  Abscess, 

Secondary  Abscess.   . 

Pyogenic  Abscess. 

Necrosis  of  Cerebral  Tissue, 

Localization  of   Primary  Lesion    Determines   the  Alternati 
Meningitis  or  Abscess,        ...... 

Possibility  of  Intracranial  Inflammation  without  Infection, 


PAGE 

42 


of 


85 
86 


TABLE    OF    CONTEXTS.  ix 


Arachnitis  a  More  Exact  Term  than  Leptomeningitis. 
Encephalitis  Always  Pyogenic,         .... 
Cirrhotic  Inflammation — Atrophy,    .... 


CHAPTER   IL 

Symptomatology. 

Direct  Lesions,         •••........     qi 

Hemorrhages,  ••••.......     92 


Unconsciousness, 
Delirium, 


93 
95 


Condition  of  the  Pupils,     .........  95 

Temperature,     ...........  gy 

Pulse, gS 

Respiration  —  Marked   Infrequency    from     Compression    of     the 

Medulla, gg 

Tabulation  of  Cases,           . 100 

Cyanosis  and  Pulmonarj'  CEdema,   .......  103 

Psychical  Disturbances,    .........  104 

Influence  of  Complications,       ........  104 

General  Contusion  of  the  Brain,      ........  107 

Variability  of  Symptoms,           ........  108 

Severe  Cases,     ...........  108 

Mild  Cases,         ...........  m 

Cases  Complicated  by  Hemorrhages, 113 

Limited  Contusion  of  the  Brain,       .         .         .         .         .         .         ,         .  114 

Laceration  of  the  Brain,            .........  115 

Temperature,     ...........  116 

Pulse  and  Respiration,      ..........  121 

Asymmetrical  Radial  Pulsation 122 

Condition  of  the  Pupils,    . 124 

Loss  of  Consciousness,      .........  125 

Psychical  Disturbances, 126 


CHAPTER   IIL 
Symptomatology — Contimced. 

Symptoms  Indicative  of  the  Localization  of  Lesions,     ....  129 

Mental  Disorders  in  Cases  of  Laceration  of  the  Frontal  Lobes,     .         .  129 
Differences  in  Symptomatology  as  the  Right  or  the  Left  Frontal  Lobe, 
or  as  the  Superficial  or  Deeper  Portion  of  the  Left  Lobe,  is 

Involved — Tabulation  of  Cases,  ......  130 

Illustrated  by  Histories  of  Pistol-Shot  Wounds,      ....  136 

Conclusions,       ...........  138 


TABLE    OF   CONTENTS. 


"AGE 

Derangements  of  Muscular  Action 138 

Paralysis. 

139 

Incoordination, 

139 

Clonic  and  Tetanic  Spasm 

139 

S3-mptoms  from  Lesion  of  Corpus  Striatum,   . 

141 

Optic  Thalamus 

141 

Fornix,       ........ 

142 

Gyrus  Fornicatus,      ...... 

142 

Pons 

143 

Temporal  Lobe, 

143 

Conjugate  Deviation 

146 

Loss  of  Urinary  and  Faecal  Control. 

147 

Secondary  Inflammations 

148 

Arachnitis, 

I4S 

General  Symptoms 

150 

Abscess 

153 

Superficial,          ..... 

153 

Deep. 

154 

Analysis  of  General  Symptoms, 

157 

Localizing  Symptoms 

159 

161 

CHAPTER    IV. 

Diagnosis. 

Unconsciousness  as  a  General  Indication  of  Traumatic  and  Idiopathic 

Characteristics  of  Opium  Narcosis, 

165 

"  Ursemic  Coma.    . 

166 

"            "  Apoplectic  Coma, 

.     166 

"  Alcoholic  Coma, 

.     166 

"             "  Traumatic  Coma, 

.     167 

Diagnosis  of  Traumatic  from  Alcoholic  Coma, 

.     168 

Coexistence  of  the  Two  Conditions, 

.     169 

Temperature,     ...... 

.     170 

Delirium,   ....... 

•     171 

•     172 

Coexistence  of  the  Two  Conditions, 

.     172 

•     173 

DiflEerentiation  of  Traumatic  Lesions  from  Each  Other, 

•     174 

•     174 

Unconsciousness,       ..... 

•     175 

Temperature,     ...... 

.     176 

Respiration . 

•     177 

Pulse 

•     177 

TABLE    OF    CONTENTS.  xi 

PAGE 

Condition  of  Pupils, -179 

Mental  Disturbances,         .........   180 

Muscular  Disorders,  .         .         .         .         .         .         .         .         .i3i 

Loss  of  Urinary  and  Fsecal  Control,         ......   182 

Aphasia — Not  from  Hemorrhage .         .182 

Unconsciousness,    Temperature,    Pulse,  and   Respiration,  as  the 

Essential  Factors  in  Diagnosis  of  Intracranial  Lesions,    .         .   185 
Secondary  Inflam.mations,        .         .         .         .         .         .         .         .         .185 

Arachnitis, .   185 

Abscess,     ............   i88 

Diagnosis,  when  of  Early  Formation,  from  Primary  Contusion,   .         .   188 
Diagnosis,  when  of  Later  Development,  from  Results  of  Vascular  Le- 
sions and  from  Tumor 189 

Symptoms  Common  to  All  Organic  Diseases  of  the  Brain,    .         .         .   igo 

Symptoms  Common  to  Abscess  and  Tumor igo 

Diagnosis  of  Abscess  from  Tumor, igi 

CHAPTER   V. 
Prognosis. 


Direct  Lesions,         ........ 

Statistical  Results  in  Five  Hundred  Original  Cases, 

Relative  Danger  of  Fractures  of  Cranial  Base  and  Vertex  Dependent 

upon  Complications.  ...... 

Relative  Danger  of  Different  Intracranial  Complications, 
Analysis  of  Recovering  Cases,         ..... 

Prognostic  Indications  from  Individual  Symptoms, 
Secondary  Inflammations,        ...... 

Arachnitis,  ........ 

Abscess 


193 
193 

195 
195 
198 
201 
204 
204 
205 


CHAPTER   VI. 

Principles  of  Treatment. 

Direct  Lesions,         ...........  206 

Shock,         .....         206 

Operation  for  Intracranial  Injuries, •      .  208 

Epidural  Hemorrhage 208 

Conditions  of  Operation.  ........  210 

Subdural  Lesions,      ..........  212 

Pial  and  Cortical  Hemorrhages,        .......  212 

General  Contusion,    ..........  214 

Laceration  of  the  Brain 215 

Arachnitis,  ...........  216 

Suramar5\  ...'........  217 

Late  Pathic  Conditions,     .........  219 

Dangers  of  Operation 220 


XI 1 


TABLE    OF    CONTENTS. 


General  Conduct  of  Operation 
General  Treatment, 
Secondary  Inflammations, 
Arachnitis, 
Abscess, 

Superficial, 
Deep, 


PAGE 

.  222 

■  223 

.  227 

.  227 

.  22S 

.  22S 

.  230 


PART    II. 


Pistol-Shot  Wounds  of  the  Head. 


CHAPTER    VII. 
Medico-Legal  Relations. 

Observations  Made  upon  the  Cadaver, 
Extracranial  Lesions, 

0.3S  cal..  Head, 

o. 3S  cal..  Bod}-, 

0.32  cal..  Head, 

0.44  cal. ,       " 

0.22  cal.,       " 
Generalization  of  Results, 
Modifying  Conditions, 
Characteristics  of  Cutaneous  Wound  of  Exit, 
How  far  Wounds  Inflicted  during  Life  Differ  from  Those 

Cadaveric  Experimentation,     ..... 
Comparative  Importance  of  Different  External  Conditions 

in  Estimating  Range  and  Calibre,    .... 
Medico-Legal  Importance  of  the  Study  of  These  Lesions, 
cessity  of  Sufficiently  Extended  Experimentation, 

Decisive  in  only  a  Limited  Number  of  Cases, 
Cranial  Lesions,        ...... 

Peculiarities  Common  to  all  Calibres  of  Ball, 
Cranial  Penetration,  .... 

0.44  cal..  Pistol  of  Most  Efficient  Type, 

0.44  cal..  Pistol  of  Inferior  Type, 

0.38  cal.,     . 

0.32  cal.,     .... 

0.22  cal.,     ;         .         .         . 

Modifying  Conditions, 
Dimensions  of  Cranial  Wounds, 

0.44  cal.,    .... 

0.38  cal 

0.32  cal..     .... 

0.22  cal.,     .... 


Produced  in 
Enumeratec 
and  the  Ne 


235 
239 
239 
250 

254 
260 
266 

276 
2  86 

289 

290 
292 

295 
297 
297 
298 
298 
300 
302 
302 
304 
306 
30S 
312 
312 
312 
314 
314 


TABLE   OF   CONTENTS. 


Xlll 


PAGE 

Summary, .   314 

Cranial  Wounds  of  Exit, 

315 

Cranial  Comminution  and  Fissuring, 

320 

0.44  cal.,     ..... 

320 

0.38  cal., 

322 

0.32  cal.,    ..... 

324 

0.22  cal.,     ..... 

324 

Intracranial  Lesions, 

326 

CHAPTER  VIIL 


Surgical  Relations. 

Symptomatology,     .... 

Profundity  of  Unconsciousness, 

Immediate  Subjective  Symptoms, 
Diagnosis,         .... 

Fluhrer's  Probe, 

Nelaton's  Probe, 

Girdner's  Telephonic  Probe, 

Use  of  Rontgen  Rays, 

Acupuncture, 

Diversion  of  the  Bullet,     . 

Examdnation  of  the  Eye  and  Orbit, 

Examination  of  Cervical  Region, 
Treatment,        ..... 

Shock,         ..... 

Several  Views  as  to  Further  Treatment, 

Illustrations  from  Published  Cases, 

Results  of  Expectant  Treatment, 

Incision  of  Dura  Mater,     . 
Operation  with  a  View  to  Drainage  only. 
Analysis  of  Published  Cases  with  Reference  to  the  Results  of  Reten 
tion  of  Bullets  within  the  Cranial  Cavity, 

Conclusions,       ...... 

Analysis  of  Published  Cases  with  Reference  to  the  Comparative  Dan- 
ger of  Retention  and  Removal  of  Bullets  Deeply  Situated 
within  the  Cranial  Cavity 

Conclusions, 
Treatment  of  Superficial  Wounds  of  Entrance  and  Exit 
Exaggerated  Estimate  of  the  Danger  of  Operation, 
Details  of  Operation,        .         .         . 
Counter-Operation,  ...... 

Circumstances  Adverse  to  Counter-Operation, 
Disinfection  and  Drainage,  ..... 
Prognosis,         ........ 

Statistics 

Treatment,    .    •   ,  •    •    •    •    • 


334 
337 
338 
342 
344 
344 
345 
346 
348 
349 
350 
35T 
353 
353 
354 
355 
356 
358 
360 

360 
366 


366 
370 
371 
372 
375 
379 
382 
384 
387 
387 
390 


XIV  TABLE    OF    CONTENTS. 


The  Condensed  Histories  of  Three  Hundred  Intra- 
cranial Traumatisms. 


CASES    verified    BY    NECROPSY. 

Fractures  of  the  Cranial  Base, 

Fractures  of  the  Cranial  Base  from  Pistol-Shot  Wound, 
Fractures  Confined  to  the  Cranial  Vertex,       ..... 
Fractures  Confined  to  the  Cranial  Vertex  from  Pistol-Shot  Wound, 
Encephalic  Injuries  without  Cranial  Fracture 


PAGE 

395 
477 
493 
503 
513 


CASES    unverified    BY    NECROPSY. 
L^nclassified 537 

Intracranial  Lesions  from  Pistol-Shot  Wounds  with  Recovery,     .         .   577 


INJURIES    OF    THE    BRAIN    AND    OF 
ITS   MEMBRANES. 

PART    I. 


GENERAL   TRAUMATIC   LESIONS. 


A     PRELIMINARY     CONSIDERATION      OF      CRANIAL 

FRACTURE. 

Injuries  of  the  head  may  be  topographically  classified 
as  superficial  or  extracranial,  cranial,  and  intracranial. 

These  may  occur  independently  or  may  variously  com- 
plicate each  other. 

The  external  injuries  may  be  excluded  as  of  no  import- 
ance in  a  consideration  of  intracranial  lesions  except  as 
aids  in  diagnosis,  and  in  the  case  of  cutaneous  wounds,  as 
a  possible  means  of  infection  in  meningitis  or  in  the  course 
of  cerebral  abscess. 

The  cranial  injuries  are  contusion  and  fracture,  and  of 
these  contusion  followed  by  consequences  of  moment  is  in- 
frequent and  has  no  closer  relation  to  intracranial  injury 
than  have  contusions  of  the  more  superficial  parts.  Frac- 
tures so  usually  complicate,  or  are  complicated  by,  struc- 
tural changes  in  the  brain  or  its  meninges ;  and  are  often 
so  directly  connected  with  the  pathic  results  of  intracranial 
lesions,  either  by  osteal  hemorrhage  or  by  affording  a 
channel  for  the  invasion  of  septogenic  germs,  as  to  justify 
some  particularity  of  attention  to  their  peculiarities. 


2  injuries  of  the  brain  and  membranes. 

Fracture. 

The  classification  of  fractures  of  the  cranium  is  prima- 
rily the  same  as  of  fractures  of  other  bones: 

I. 

Simple. 
Compound. 
Comminuted. 
Complicated. 

II. 

Complete. 
Incomplete. 

III. 

Direct. 
Indirect. 
Secondarily   or   specifically   they   may   be   again   sub- 
divided : 

I. 

Fractures  of  the  vault. 
Fractures  of  the  base. 

II. 
Linear  or  fissured. 
Punctured. 
Depressed. 

The  last  may  be  either  singly  or  doubly  camerated. 

A  much  simpler  and  therefore  better  classification, 
which  has  the  additional  advantage  of  a  definite  relation 
to  diagnosis,  prognosis,  and  treatment,  may  be  derived 
from  the  one  just  presented. 


PRELIMINARY   CONSIDERATIONS.     .  3 

I. 

Integral. 

Complicated. 
Non- complicated, 

II. 

Regional. 

Fractures  of  the  vault. 
Fractures  of  the  base. 

Fractures  of  either  the  vault  or  base  may  be  simple, 
compound,  or  comminuted,  punctured,  linear,  or  depressed, 
direct  or  indirect,  though  the  relative  frequency  of  these 
subdivisions  varies  greatly  in  the  two  primary  forms. 
Fractures  of  the  base  are  ordinarily  simple  and  linear, 
■while  those  of  the  vault  are  not  infrequently  compound, 
comminuted,  depressed,  or  punctured.  Both  are  almost 
invariably  caused  by  direct  violence,  and,  while  both  may 
be  either  complicated  or  non-complicated,  a  complication 
in  fracture  of  the  base  is  more  characteristic  and  often  oc- 
casions not  only  differences  in  prognosis  but  in  methods  of 
diagnosis  and  requirements  of  treatment.  The  presence 
or  absence  of  a  complication  is  of  essential  importance, 
and  as  its  recognition,  probable  result,  and  treatment  may 
be  influenced  by  the  region  of  injury,  the  corresponding 
divisions  of  fracture,  whether  or  not  they  are  accepted  as 
a  formal  basis  of  classification,  must  always  be  those  of  the 
greatest  practical  value.  The  other  distinctions  which 
may  be  made  in  the  characters  of  a  fracture,  if  not  insig- 
nificant, are  at  least  of  minor  importance;  whether  the 
osteal  wound  be  simple  or  compound,  linear  or  depressed, 
or  comminuted,  is  of  little  moment  in  view  of  the  present 


4  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

resources  of  surgery ;    and  one  is  often  converted  into  the 
other  in  the  course  of  preliminary  examination. 

All  fractures  which  involve  the  base,  though  originat- 
ing in  the  vault,  are  to  be  regarded  as  basic,  because  it  is 
upon  the  implication  of  this  region  that  their  characteristic 
conditions  depend.  In  a  certain  number  of  cases,  violence 
is  inflicted  through  the  eye,  nose,  or  mouth,  or  inferior 
temporal  region,  by  bullets  or  exceptionally  by  sharp- 
pointed  instruments ;  but  exclusive  of  these  there  are  few 
instances  in  which  a  fracture  of  the  skull  does  not  have  its 
beginning  in  the  vault.  In  the  appended  series  of  cases, 
as  verified  by  necropsic  examination,  there  are  146  frac- 
tures of  the  base,  of  which  18  were  from  pistol  shot  and  i 
from  another  form  of  violence  directly  applied  to  the  point 
of  basic  lesion  ;  there  are  34  fractures  confined  to  the  vault, 
of  which  14  were  from  pistol  shot;  in  147  fractures  of  the 
vault,  therefore,  not  of  pistol-shot  origin,  the  base  was  im- 
plicated in  127.  There  existed  in  but  12  of  the  127  a  basic 
fissure  independent  of  a  fracture  of  the  vault,  and  in  sev- 
eral (6)  of  these  another  fissure  extended  from  vault  to 
base.  These  12  cases  in  which  force  was  indirect,  that  is 
to  say,  in  which  the  fracture  began  and  ended  in  the  base, 
though  the  force  was  applied  to  the  vault  at  a  distance 
and  transmitted  through  parts  which  maintained  their  in- 
tegrity, are  instances  of  what  has  sometimes  been  called 
injury  by  contrecoup,  and  similar  to  what  is  much  more 
frequently  encountered  in  the  brain.  In  each  case  by  the 
history  as  well  as  by  existent  wound  or  contusion,  it  was 
proven  that  the  force  was  primarily  exerted  upon  the 
vault,  nor  was  there  in  any  one  the  slightest  reason  to 
suspect  that  the  effect  of  violence  had  been  conveyed 
through  the  spinal  column.     The  concurrence    of  direct 


PRELIMINARY    CONSIDERATIONS.  5 

fracture  was  noted  in  6  cases  and  there  was  intervening 
brain  laceration  in  all  but  2.  The  direct  force  in  6  cases 
was  applied  to  the  parietal  region,  and  in  3  of  these  was 
transmitted  to  an  orbital  plate  or  to  the  crista  galli  and 
sphenoid  surface ;  in  5  it  was  applied  to  the  occiput,  and 
in  3  of  these  also  was  transmitted  to  the  orbital  plates ;  but 
in  the  others  the  indirect  fracture  was  produced  in  the 
middle  or  posterior  fossa  or  upon  the  surface  of  the  inter- 
vening petrous  portion.  It  is  evident  therefore  that  it  is 
not  always  the  most  fragile  portions  of  the  cranium  which 
give  way.  In  10  of  the  12  cases  the  counterfracture  was 
no  more  than  a  fine  short  fissure,  which  could  have  had  no 
influence  in  the  display  of  symptoms  and  could  be  of  no 
real  importance  in  contravening  the  general  statement  that 
fractures  of  the  base  are  continuations  of  fissures  which 
have  their  origin  in  the  vault  at  the  point  of  injury.  In 
the  2  cases  remaining  the  counterfracture  was  directly 
contributive  to  the  death  of  the  patient.  In  one  the  fis- 
sure widely  curved  through  both  orbital  plates  and  the 
fractured  edge  of  each  was  raised  and  tilted  forward,  and 
on  the  right  side  it  deeply  lacerated  the  base  of  the  frontal 
lobe ;  the  frontal  sinus  was  also  opened  into  the  cranial 
cavity.  In  the  other  a  smaller  osseous  lesion  was  no  less 
disastrous ;  the  fissure  was  fine  and  extended  only  from 
the  anterior  inferior  angle  of  the  parietal  bone  across  the 
squamous  portion  of  the  temporal  to  the  petrous  junction, 
but  a  minute  triangular  portion  of  the  inner  table  was  de- 
tached and  had  lacerated  the  arteria  meningea  media  at  its 
bifurcation  with  resulting  profuse  and  fatal  hemorrhage. 

The  conditions  which  govern  the  character  and  extent 
of  cranial  fractures  are  the  violence  of  impact,  the  extent 
of  surface  involved,  and  the  physical  properties  of  the  era- 


6  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

nium,  its  elasticity,  composite  structure,  degree  of  thick- 
ness or  density,  and  its  vaulted  form.  The  concentration 
of  force  when  the  head  is  struck  by  an  object  of  limited 
size  and  definite  outline  tends  to  the  production  of  com- 
minuted and  depressed  fractures  confined  to  the  region  of 
impact.  The  diffusion  of  force  when  the  head  itself  is  the 
impinging  object,  as  in  falls  from  a  distance,  equally  leads 
to  extended  fissures  with  or  without  crushing  at  the  point 
of  direct  injury.  The  observation  of  cases,  however, 
shows  that  the  physical  properties  of  the  cranial  vault  are 
ordinarily  such  that  even  when  force  is  concentrated,  if 
the  instrument  of  violence  be  other  than  a  pistol  shot  or 
some  sharp  weapon,  the  effect  is  much  more  than  likely  to 
be  diffused.  A  great  degree  and  concentration  of  violence 
and  a  tenuity  or  brittleness  of  a  part  undoubtedly  favor  re- 
striction of  fracture  to  the  site  of  injury,  as  wider  diffusion 
of  force  and  the  elasticity  and  average  density  of  the  skull 
account  for  its  more  frequent  extension  by  fissure  to  a  dis- 
tance. 

The  precise  mechanism  of  basic  fracture  has  been  ex- 
perimentally investigated  by  various  surgeons,  who  have 
arrived  at  somewhat  different  conclusions.  The  recent 
summary  of  the  opinions  of  these  experimenters  by  Ros- 
well  Park,  in  Dennis'  "System  of  Surgery,"  precludes  the 
necessity  for  their  repetition. 

The  usual  basic  fracture  unquestionably  extends  be- 
tween the  region  in  which  primary  injury  is  received  and 
the  corresponding  basic  fossa  of  the  same  side ;  and  the 
explanation  of  Aran,  that  force  follows  the  shortest  anatomi- 
cal route  and  in  the  direction  in  which  there  is  least 
resistance,  seems  adequate.  If  the  middle  fossae,  alone  or 
in  contiguity,  suffer  oftener  than  the  others,  it  is  because 


PRELIMINARY   CONSIDERATIONS.  7 

the  middle  region  of  the  vault  is  most  exposed  to  violence. 
If  force  is  too  great  for  its  entire  expenditure  at  the  point 
of  impact,  or  resistance  too  obstinate,  it  traverses  the  bone 
till  exhausted ;  that  it  should  be  propagated  in  direct  lines, 
modified  only  by  inequalities  of  resistance,  is  as  plainly  in 
accordance  with  natural  laws  as  the  riving  of  wood  or  iron 
by  the  wedge.  In  some  instances  the  force  is  too  great  to 
be  restrained  by  any  resistance  which  it  may  encounter, 
and  transgresses  the  limits  which  may  be  set  by  "  natural 
buttresses,"  or  abandons  the  squamous  to  folloAV  its  direct 
course  through  the  denser  petrous  portion.  The  theory  of 
Hare,  that  the  elastic  skull,  compressed  between  two  poles, 
like  a  melon  gives  way  in  the  middle,  and  that  the  fracture 
extends  in  both  directions,  seems  far-fetched  and  not  sub- 
stantiated by  appearances  which  the  fissures  present  when 
examined  for  corroboration.  The  comparison  of  the  exact 
site  of  superficial  contusion  w^ith  the  commencement  of  a 
linear  fracture  of  the  vault  indicates  that  not  infrequently 
force  may  be  transmitted  through  the  bone  for  a  certain 
distance  before  disruption  begins. 

The  limited  number  of  cases  in  which  independent 
fractures,  more  or  less  trivial,  occur  at  the  base,  with  or 
without  a  fracture  of  the  vault,  are  less  readily  explained 
by  the  direct  propagation  of  force  through  the  cranial  wall. 
The  brain  substance  and  the  bone  have  each  been  regarded 
as  the  medium  of  transmission.  In  the  well-known  case 
of  the  assassination  of  a  president  of  the  United  States,  in 
which  a  pistol-shot  fracture  of  the  occiput,  with  lodgement 
of  the  bullet  near  the  corpus  striatum,  caused  comminution 
of  both  orbital  plates,  Mr.  Longmore  believes  that  the  or- 
bital fracture  was  due  to  "  transmitted  undulatory  strokes 
or  sudden  impulse  of  the  brain  substance  against  these 


8  INJURIES    OF    THE    BRAIN   AND    MEMBRANES. 

bony  layers."     This  may  be  possible  in  so  thin  and  fragile 
laminae  as  the  orbital  plates,  but  it  is  insufficient  to  explain 
the  Assuring  of  bony  parts  so  dense  as  the  petrous  portion 
of  the  temporal,  or  the  floor  of  a  middle  or  posterior  basic 
fossa.     There  are  also  the  special  defects  in  Mr.   Long- 
more 's   explanation    of    the    counterfracture    in    the   case 
quoted,  that  it  ignores  the  fact  that  the  direction  of  force 
was  parallel  to  the  orbital    surfaces,   and  that  it  fails  to 
account  for  the  upward  dislocation  of  the  fragments.     In 
simple  counterfissure  of   the   base,   it  would   seem  more 
probable  that  the  distant  lesion  was  due  to  the  direct  trans- 
mission of  force  through  the  bone.     In  view  of  the  numer- 
ous instances  in  which  force  is  transmitted  for  a  limited 
distance  through  the  lateral  wall  of  the  vault  before  cleav- 
age begins,  it  is  not  illogical  to  suppose  that  in  others 
exceptionally   noted    its   course   should    have    been    even 
longer  continued  before  its  eruption.     In  counterfissures 
confined  to  the  petrous  portion  or  to  the  contiguous  basic 
fossae,  it  is  scarcely  possible  to  conceive,  though  the  skull 
might  be  compressed  to  the  point  of  bursting,  that  the 
rupture  should  have  occurred  in  its  most  rigid  if  not  abso- 
lutely inelastic  portion.     The  effect  of  distant  violence,  in 
causing  not  only  indirect  fracture  but  limited  osteal  hyper- 
aemia  and  extravasation,  is  illustrated  in  Case  CXXV.  of 
the  appended  series  and  represented  in  Fig.  44.     There  are 
occasional  indirect  basic  fractures  which  are  more  readily 
explicable,  or  even  necessarily  dependent,  upon  the  suppo- 
sition that  the  skull  has  been  violently  compressed.     In 
Case  CIV.  of  the  appended  series,  the  circumstances  of  in- 
jury and  the  effects  which  it  produced  concur  to  make  this 
explanation  inevitable.     The  head  was  struck  upon  the 
occiput  by  a  descending  elevator  and  forced  forward,  with 


PRELIMINARY    CONSIDERATIONS.  9 

the  chin  resting  upon  an  iron  railing  as  an  approximately 
fixed  point.  Fracture  was  confined  to  the  anterior  basal 
fossae,  and  extended  from  the  posterior  border  of  the  crib- 
riform plate  upon  the  right  side  by  a  wide  sweep  outward 
and  forward,  and  then  inward  through  both  orbital  plates. 
The  roof  of  the  orbit  was  elevated  and  tilted  forward,  and 
the  frontal  sinuses  were  opened  into  the  cranial  cavity. 
Continued  force  and  resistance  acted  at  the  extremities  of 
the  occipito-mental  diameter,  and  violent  disruption  oc- 
curred in  a  vulnerable  region  at  its  centre.  In  a  recov- 
ering case,  No.  CCLIX.,  in  which  force  was  similarly 
applied,  fracture  through  the  anterior  and  middle  fosss 
into  the  petrous  portion  was  doubtless  produced  by  the 
same  mechanism. 

It  is  impossible  to  believe  that  the  mechanism  of  frac- 
ture is  always  the  same.  In  a  careful  necropsic  examina- 
tion of  cranial  fractures  included  in  the  appended  series  of 
cases,  there  are  a  rather  limited  number  which  immedi- 
ately involve  the  base,  all  but  one  from  bullet  wound,  and 
a  scarcely  larger  number  which  may  be  termed  indirect 
and  are  of  questionable  origin.  All  the  others,  more  than 
ninety  per  cent,  of  the  entire  number,  are  the  result  of 
violence  inflicted  upon  the  vault,  and  of  these  more  than 
seventy-eight  per  cent,  extend  to  the  base.  If  pistol-shot 
fractures  be  excluded,  the  percentage  of  those  which 
extend  from  vault  to  base  is  increased  to  eighty -five. 
The  inspection  of  basic  fractures  of  this  predominating 
class  has  suggested  nothing  but  an  origin  at  the  point  of 
injury.  They  negative  in  their  appearance  Hare's  opin- 
ion that  diffuse  bloAvs  produce  their  effect  at  a  distance 
from  the  point  of  application,  and,  as  such  evidence  is 
entitled  to  more  weight  than  conclusions,  which  must  be 


10  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

more  or  less  theoretical,  derived  from  experimentation 
upon  the  cadaver,  these  fractures  must  be  regarded  as  in 
general  the  product  of  direct  violence.  The  very  small 
proportion  of  basic  fissures  which  are  obviously  indirect 
are  very  likely  of  variable  as  well  as  questionable  origin ; 
apart  from  such  unusual  antecedent  conditions  as  severe 
and  demonstrable  compression  of  the  head  between  two 
fixed  points,  exemplified  in  Case  CIV.,  they  afi'ord  no 
positive  etiological  data;  whether  force  is  generated  by 
insupportable  distortion  of  the  elastic  vault,  or  is  trans- 
mitted like  the  electric  current  without  change  in  the 
osseous  structure  traversed  to  its  point  of  discharge  in 
some  basic  region,  or  is  propagated  by  undulations  in  the 
brain  substance,  is  a  problem  still  confined  for  its  solution 
to  the  domain  of  theory  and  of  individual  probability. 
These  indirect  fractures  have  been  called  contrecoup,  since 
they  are  developed  in  a  region  directly  or  approximately 
opposite  to  that  in  which  violence  has  been  inflicted,  and 
the  term  may  be  conveniently  and  allowably  retained  with- 
out involving  a  theory  of  their  production ;  its  application 
to  fissures  of  the  base  which  are  continuous  with  fractures 
of  the  vault  is  unwarranted, 

A  study  of  the  one  hundred  and  eighty  cranial  fractures 
in  the  appended  series  of  original  cases  which  were  sub- 
jected to  post-mortem  examination  discloses  many  facts 
concerning  the  details  of  their  character  and  mechanism 
which  are  of  interest  and  value,  but  are  not  essential  to  the 
discussion  of  intracranial  lesions. 

The  peculiarities  of  depressed,  comminuted,  or  perfo- 
rating forms  of  cranial  fracture  are  adequately  described 
in  general  text-books  of  surgery.  Simply  as  osseous  le- 
sions they  have  been  robbed  of  their  significance  by  ad- 


PRELIMINARY    CONSIDERATIONS.  II 

vancements  in  the  methods  of  surgical  practice.  In  their 
greater  liability  to  intracranial  complication  they  retain 
their  special  importance ;  a  degree  of  violence  sufficient  to 
comminute  the  bone  is  likely  to  extend  its  effects  to  the 
subjacent  structures ;  depressed  fragments  become  new 
sources  of  injury;  and  perforating  fractures  almost  neces- 
sarily involve  cerebral  or  dural  wound.  Their  results  are 
more  serious  and  their  treatment  demands  more  active 
intervention  than  do  simple  fissures,  but  it  is  by  reason  of 
the  complication  rather  than  by  the  greater  injury  Avhich 
the  bone  has  sustained.  The  necessity  of  removing  com- 
minuted or  of  elevating  depressed  fragments  of  bone 
scarcely  increases  the  gravity  of  prognosis.  The  most 
insignificant  fissure  may  be  associated  with  fatal  in- 
tracranial hemorrhage,  while  the  largest  comminution,  if 
uncomplicated,  may  be  devoid  of  danger.  It  is  the 
complication  and  not  the  fracture  which  dominates  the 
case. 

The  complications  of  cranial  fracture  are  cerebral  and 
meningeal,  and  in  either  one  may  be  laceration,  contusion, 
hemorrhage,  or  septic  inflammation ;  and  to  these  may  be 
added  hemorrhage  from  the  osteal  vessels.  The  septic 
inflammations  are  rather  sequelae  than  complications,  since 
they  are  not  direct  products  of  the  same  violence  which 
causes  the  fracture,  but  the  result  of  a  later  infection  for 
which  the  fracture  has  afforded  opportunity.  All  these 
conditions  may  equally  occur  in  the  absence  of  fracture,  as 
primary  and  independent  lesions,  and  as  such  will  be 
given  later  consideration.  Fractures  which  are  practically 
uncomplicated  may  occur  both  in  the  vault  and  in  the  base, 
though  some  degree  of  cerebral  contusion  will  probably 
attend  even  the  most  inconsiderable  of  simple  fissures.     If 


12  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

the  symptoms  of  this  contusion  are  trivial  and  transient,  it 
may  be  properly  disregarded  in  classification  as  well  as  in 
treatment. 

Symptomatology  and  Diagnosis. 

The  very  frequent  coincidence  of  fracture  with  intra- 
cranial lesion  has  led  to  much  confusion  in  symptomatol- 
ogy and  consequent  prognosis.  Loss  of  consciousness 
and  variations  in  pulse,  temperature,  and  respiration, 
with  other  undoubted  indications  of  intracranial  com- 
plication, are  still  enumerated  among  the  symptoms  of 
fracture.  These  inaccuracies  are  of  consequence,  since 
a  lack  of  well-defined  conception  of  the  nature  of 
lesions  or  of  the  significance  of  symptoms  begets  errors 
of  treatment. 

The  direct  effects  of  fracture  are  few  and  usually  not 
difficult  to  discover.  It  may  be  briefly  stated  that  fracture 
of  the  vault  is  to  be  recogized  by  tactile  or  visual  sense; 
that  these  methods  are  always  practicable ;  that  no  others 
are  defensible;  and  that  there  is  no  justification  for  the 
neglect  to  resort  to  both  when  one  is  insufficient  for  exact 
diagnosis.  If  the  fracture  be  compound,  there  can  be  no 
doubt  of  its  existence,  provided  the  wound  be  of  sufficient 
size  to  disclose  the  osseous  surface ;  if  the  wound  be  too 
small  for  thorough  exploration,  the  fracture  may  be  re- 
garded as  essentially  of  the  simple  variety.  The  simple 
fracture,  if  depressed,  may  be  often  recognized  by  palpa- 
tion through  the  layers  of  the  scalp,  but  if  doubt  exists,  or 
if  from  symptoms  of  intracranial  complication  suspicion 
arises,  certainty  should  be  reached  by  incision  and  direct 
inspection.  This  covers  the  whole  ground  of  diagnosis — 
tactile  or  visual    examination,  and,  if   necessary  to   that 


PRELIMINARY   CONSIDERATIONS.  1 3 

purpose,  unhesitating  and  sufficient  incision  down  to  the 
cranial  surface. 

The  diagnosis  of  fracture  of  the  base  is  sometimes 
equally  direct,  but  is  oftener  inferential,  and  it  may  be 
entirely  conjectural.  If  continuous  with  a  fracture  of  the 
vault  which  has  attracted  attention,  it  should  be  incident- 
ally discovered  in  the  course  of  the  examination  necessi- 
tated at  the  site  of  immediate  injury,  as  fissures  are  readily 
traceable  to  a  point  at  which  their  implication  of  the  base 
becomes  assured.  In  a  very  large  proportion  of  cases, 
however,  the  basic  fracture  begins  as  a  simple  fissure  at 
the  vertex,  or  upon  the  lateral  aspect  of  the  vault,  and  with 
an  absence  of  conditions  w^hich  suggest  direct  exploration. 
The  indications  of  intracranial  injury  may  then  afford 
reasons  for  inferring  the  existence  of  basic  fracture,  but 
not  with  absolute  certainty,  since  the  occurrence  of  inde- 
pendent traumatic  lesions  is  not  infrequent. 

There  is  one  direct  symptom  of  the  fracture  which 
when  present  may  be  almost  pathognomonic:  it  is  an 
osteal  or  intracranial  hemorrhage  w^hich  through  some 
channel  becomes  visible  at  or  beneath  the  surface.  Its 
source  may  be  the  vessels  of  the  diploe,  of  the  meninges, 
or  of  the  brain,  and  its  escape  may  be  from  the  ear,  nose, 
or  mouth,  or  into  the  subconjunctival  or  subcutaneous  cel- 
lular tissue.  The  fracture  very  generally  traverses  some 
portion  of  the  base  w^hich  permits  the  appearance  of  the 
blood  externally  in  one  or  the  other  of  these  situations. 
The  comparative  frequency  with  which  different  basic 
regions  are  involved,  and  the  significance  of  various  ex- 
ternal hemorrhages  of  internal  origin,  are  suggested  by  a 
summary  of  these  fractures  included  in  the  appended  gen- 
eral series. 


14  injuries  of  the  brain  and  membranes. 

Fractures  of  the  Base. 
I.   Results. 

Recovered,  .  .  .         .  .no 

Died, 176 

II.   Necropsies. 

Fractures  continued  from  vault,  .   133 

Fractures  confined  to  base,  .  .13 

III.  Hemorrhages. 

Fractures  with   external  hemorrhage,     67 
Fractures    without     external     hemor- 
rhage,        61 

IV.  Regions  of  Fraeture  and  External  Site  of  Hemor- 

rhage (pistol-shot  fractures  excluded). 

1.  Petrous  Portion. 

Hemorrhage  from  ear,  .         .       5 

No  hemorrhage,   ....       4 — 9 

2.  Petrons  Portion  and  Middle  Fossa. 

Hemorrhage  from  ear,  .         .  6 

Hemorrhage  from  ear  and  nose,  .  2 
Hemorrhage     from      ear,     nose, 

and  mouth,        .         .         .         .  i 

No  hemorrhage,   .         .         .         .  3 — 12 

3.  Petrous  Portion  and  Posterior  Fossa. 

Hemorrhage  from  ear,  .         .       5 

Hemorrhage,  subcutaneous,  mastoid,  i 
Hemorrhage  from  ear  and  nose,  .  3 
No  hemorrhage,    ....       3 — 12 

4.  Petrous  Portion  ; — Middle  and  Posterior  Fosses. 

Hemorrhage  from  ear,  .         .       6 

Hemorrhage  from  nose,  .  .  3 
Hemorrhage   from  ear  and  mouth,   i 


PRELIMINARY    CONSIDERATIONS.  I  5 

Hemorrhage   from     ear,    mouth, 

and  nose,  .         .         .         •       2 

No  hemorrhage,    .         .         •         •       2     14 

5.  Petrous  Portion;  Middle  and  Anterior  Fosses. 

Hemorrhage  from  ear,  .         •       i 

Hemorrhage  from  ear  and  nose,  .  4 
Hemorrhage      from      ear,     nose, 

and  mouth,  .  •  •  •  ^ 
Hemorrhage  from   ear   and  nose 

and  subconjunctival,  •         .       i 

Hemorrhage,  subconjunctival,       .       1—8 

6.  Both  Petrous  Portions  and  All  Basic  Fosses. 

Hemorrhage  from  one  ear,   .         .       i 
Hemorrhage  from  both  ears,  nose, 

and  mouth,        .         •         •         •       ^     ^ 

7.  Petrous  Portion  and  All  Basic  Fosscb  of  the  Same 

Side. 
Hemorrhage  from  ear,  .         •       i 

Hemorrhage     from      ear,     nose, 

and  mouth,         .  •  •  •        ^     ^ 

8.  Petrous  Portion;    Anterior  and  Middle  Fosses; 

Basilar  Process. 
Hemorrhage      from      ear,     nose, 
and  mouth,         .         •         •         •       ^ 
9..  Anterior  Fosscb. 

Hemorrhage  from  nose,         .         •       2 
Hemorrhage  from  nose  and  mouth,  i 
Hemorrhage,  subconjunctival, 
No  hemorrhage,   .         •         •         ■ 
10.  Middle  Fosses. 

Hemorrhage  from  nose,         .         •       3 
Hemorrhage,  subconjunctival, 


I 

5—9 


I 


l6  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

No  hemorrhage,   ....      13 — 17 

1 1 .  Posterior  Fosses. 

No  hemorrhage,    .  .  .         .21 

12.  A  nterior  and  Middle  Fossee. 

Hemorrhage  from  nose,         .  .       6 

Hemorrhage,     subconjunctival  in 

both  eyes,           .          .          .  .        i 

Hemorrhage,  subjunctival,  in  both 

eyes,  nose,  and  mouth,      .  .       i 

No  hemorrhage,    .          .          .  .        5 — 13 

1 3 .  Posterior  and  Middle  Fossce. 

Hemorrhage  from  nose,         ,  .        i 

No  hemorrhage,    ....       4 — 5 

14.  Posterior  and  Anterior  Fosses. 

Hemorrhage,  nose,        .  .  .        i 

1 5 .  Anterior,  Middle,  and  Posterior  Fosses. 

Hemorrhage  from  nose,         .  .        i 

No  hemorrhage,   ....        i — 2 
V.    Sununary  of  External  Sources  of  Hemorrhages. 
Hemorrhage  from  ear,  .         .     26 

Hemorrhage  from  ear  and  nose,  .  9 
Hemorrhage  from  ear  and  mouth,  i 
Hemorrhage       from      ear,     nose, 

and  mouth,         ....       6 
Hemorrhage  from  ear,   nose,  and 

subconjunctival,         .  .  .        i 

Hemorrhage  from  nose,         ,  .17 

Hemorrhage  from  mouth,  .  .  i 
Hemorrhage    from    nose,    mouth, 

and  subconjunctival,  .  .        i 

Subconjunctival  hemorrhage,  .  4 
Subcutaneous,  mastoid  hemorrhage    i — 67 


PRELIMINARY   CONSIDERATIONS.  1 7 

This  study  of  hemorrhages  has  been  confined  to  the 
first  class  of  basic  fractures,  those  in  which  fissure  extends 
from  a  site  of  injury  in  some  part  of  the  vault.  The  cases 
in  which  fracture  originates  in  the  base  are  almost  exclu- 
sively pistol-shot  wounds,  and  are  not  often  attended  by 
distant  hemorrhages  and  rarely  involve  a  question  of  re- 
gional diagnosis. 

The  inferences  to  be  derived  from  the  tabular  analyses 
are  so  obvious  as  scarcely  to  call  for  explanatory  comment. 
It  will  be  observed  that  hemorrhage  from  the  ear  has  oc- 
curred in  more  than  one-third  of  the  total  number  of 
cases,  in  all  of  which  the  petrous  portion  has  been  impli- 
cated; that  hemorrhage  from  the  nose  has  occurred  in 
more  than  one-fourth  of  all  the  cases,  and  when  significant 
has  followed  fracture  of  an  anterior  fossa  or  of  the  ante- 
rior part  of  a  middle  fossa;  that  there  has  been  subcon- 
junctival hemorrhage  in  six  cases,  in  all  of  which  the 
fracture  traversed  an  anterior  fossa;  that  buccal  hemor- 
rhage has  been  noted  three  times,  twice  in  conjunction 
with  epistaxis;  and  that  the  subcutaneous  hemorrhage 
resulted  from  an  inclusion  of  the  mastoid  process  in  a 
fracture  through  the  posterior  fossa.  The  anatomical 
necessity  which  absolutely  limits  these  external  indications 
to  fracture  of  positively  definite  regions  is  manifest.  The 
causes  of  their  frequent  absence  in  fractures  of  the  same 
arbitrarily  defined  basic  fossae  are  not  less  obvious.  If  the 
fracture  of  the  petrous  portion  does  not  involve  the  audi- 
tory cavities,  or  that  of  the  middle  fossa  involve  the  sphe- 
noid bone,  there  can  be  no  escape  externally  of  the  blood 
effused;  if  the  fracture  of  the  anterior  fossse  does  not 
traverse  the  ethmoid  bone,  and  the  injury  to  the  orbital 
plates  is  trivial,  the  slight  hemorrhage  which  it  occasions 


1 8  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

still  fails  of  outlet;  the  only  possible  route  by  which  blood 
extravasated  in  the  posterior  fossas  can  reach  the  surface 
is  through  the  fasciae  of  the  neck,  except  when  the  mas- 
toid process  is  implicated,  when  it  may  force  its  way 
through  the  periosteum  and  be  visible  subcutaneously  be- 
hind the  ear.  The  amount  of  hemorrhage  from  an  occip- 
ital fracture  is  insufficient  often  to  penetrate  the  deeper 
cervical  fascias,  unless  it  be  from  a  pistol-shot  wound,  and 
its  becoming  subcutaneous  is  only  a  recognizable  possi- 
bility. The  occurrence  of  a  visible  hemorrhage  as  an  in- 
dication of  simple  fracture  of  the  base  depends  upon  the 
implication  of  the  mastoid  or  petrous  portions  of  the  tem- 
poral, the  ethmoid  or  sphenoid,  or  the  orbital  processes 
of  the  frontal  bone;  and  its  undoubted  value  as  a  symp- 
tom, positive  or  negative,  is  dependent  upon  the  relation, 
suggested  by  Aran,  which  these  parts  bear  to  the  regions 
of  the  vault  most  exposed  to  injury.  The  apparent  pro- 
portion of  basic  fractures  attended  by  external  hemor- 
rhage is  somewhat  diminished  by  the  inclusion  in  the  to- 
tality of  cases  of  a  certain  number  in  which  the  early 
history  was  imperfect  or  absent,  and  in  which  the  hemor- 
rhage  might  have  been  present  but  was  not  assumed. 

It  is  possible  that  these  hemorrhages  may  occur  as  a 
coincidence  rather  than  as  a  result  of  fracture,  though  their 
interpretation  in  such  an  event  is  not  likely  to  be  difficult. 
A  hemorrhage  from  the  ear  accompanying  a  pistol-shot 
wound  of  the  temporal  fossa  was  found  in  Case  CXX XVIII. 
to  have  resulted  from  a  rupture  of  the  tympanum  by  con- 
cussion, but  extremities  of  violence  by  blows  or  falls  upon 
the  head,  which  have  shattered  the  vault  or  base,  have  not 
incidentally  produced  a  similar  lesion,  nor  can  such  a  re- 
sult be  expected  under  any  conceivable  circumstances  apart 


PRELIMINARY   CONSIDERATIONS.  I9 

from  the  shock  of  an  explosive  at  close  contact.  A  wound 
of  the  external  meatus  may  also  occasion  a  moderate  hem- 
orrhage, or  blood  from  a  wound  of  the  scalp  which  has 
filled  this  canal  may  be  momentarily  deceptive,  but  such 
sources  of  error  are  eliminated  in  the  preliminary  exami- 
nation. If  ordinary  care  be  exercised  in  excluding  these 
occasional  non-essential  hemorrhages,  this  direct  symptom 
may  be  regarded  as  fairly  pathognomonic.  A  failure  to 
discover  the  wound  of  the  tympanum  is  not  material,  since 
when  linear  it  may  be  closed  and  invisible  after  hemor- 
rhage has  ceased,  but  a  lesion  of  the  external  meatus  can- 
not be  hidden  from  observation. 

The  amount  of  blood  which  escapes  from  the  ear,  or  the 
period  at  which  hemorrhage  occurs,  its  continuance,  or  its 
relation  to  serous  discharges,  while  perhaps  indicative  of 
the  extent  of  cranial  or  internal  lesion,  is  not  essential  to 
the  recognition  of  a  petrous  fracture.  The  simple  knowl- 
edge that  the  hemorrhage  exists,  with  exclusion  of  such 
possibilities  of  error  as  have  been  suggested,  should  be 
sufficient  to  establish  the  fact  that  this  part  has  been  frac- 
tured. The  promptitude,  freedom,  and  persistence  of  a 
hemorrhage  from  the  ear  which  succeeds  an  injury  to  the 
head  merely  confirm  the  opinion  which  an  otherwise  in- 
explicable effusion  has  justified,  and  to  this  extent  are  fac- 
tors in  the  case. 

The  subconjunctival,  nasal,  and  buccal  hemorrhages 
are  less  frequently  positively  diagnostic.  Direct  orbital 
contusions  which  involve  the  eye,  or  epistaxis  from  super- 
ficial injuries  of  the  nose,  may  be  coincident  with  basic 
fracture,  and  the  estimate  of  the  clinical  value  of  a  hemor- 
rhage in  one  of  these  situations  may  therefore  require 
careful  inquiry  into  the  manner  in  which  injury  was  re- 


20  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

ceived,  and  a  study  of  all  the  attendant  symptomatic  con- 
ditions. If  the  history  shows,  and  the  superficial  lesions 
confirm,  a  limitation  of  the  field  of  violence  to  a  cranial 
region,  and  there  is  evidence  of  intracranial  complication, 
the  dependence  of  an  ocular  or  nasal  hemorrhage  upon 
fracture  can  be  properly  inferred ;  while  the  existence  of  a 
contusion  of  the  nose  or  of  an  ecchymosis  of  the  face  or 
orbit  will  render  its  origin  more  or  less  uncertain.  There 
are  really  few  cases  in  which  even  this  class  of  hemor- 
rhages cannot  be  correctly  interpreted.  The  amount  of 
blood  lost  or  extravasated  in  this  instance  is  of  more  im- 
portance than  when  the  ear  is  the  seat  of  discharge.  An 
extensive  subconjunctival  effusion  or  a  profuse  flow  from 
the  nose  at  the  outset,  with  perhaps  subsequent  hsema- 
temesis,  affords  a  stronger  presumption  of  fracture  than 
trivial  loss  or  discoloration,  which  might  have  been  caused 
by  trifling  injury.  After  the  lapse  of  twenty-four  hours 
the  beginning  of  a  slow  oozing  from  the  nose  or  of  a 
spreading  discoloration  beneath  the  subconjunctiva  is 
more  significant. 

The  relative  proportion  of  fractures  of  the  base  indi- 
cated by  the  external  appearance  of  osteal  or  intracranial 
hemorrhage  is  greatly  increased  when  comparison  is  ex- 
tended to  the  whole  number  of  cases  observed.  In  115 
cases  in  which  fracture  extended  from  vault  to  base,  com- 
prising recoveries  as  well  as  deaths  in  which  necropsy  was 
unattainable,  99,  or  eighty-six  per  cent.,  were  attended  by 
external  or  superficial  hemorrhage ;  when  no  characteristic 
hemorrhage  was  present,  diagnosis  was  made  by  incision. 
In  the  aggregate  of  this  class  of  fractures,  224  recoveries, 
and  deaths  both  with  and  without  necropsic  examination, 
154,  or  seventy  per  cent.,  were  associated  with  a  visible 


PRELIMINARY   CONSIDERATIONS.  2  1 

hemorrhage  which  could  be  considered  diagnostic.  It  is 
evident  that  the  escape  of  blood  externally,  notwithstand- 
ing its  obscurity  in  some  instances  and  its  failure  of  recog- 
nition in  others,  has  in  itself  been  sufficient  to  determine 
the  existence  of  fractured  base  in  a  very  large  majority  of 
cases  included  in  the  appended  summary  of  observations. 

There  are  besides  hemorrhage  direct  symptoms,  of  oc- 
casional or  exceptional  occurrence,  which  may  be  of  great 
diagnostic  value.  The  escape  of  brain  matter  from  the 
ear  is  absolutely  pathognomonic,  not  only  of  petrous  frac- 
ture but  of  cerebral  laceration.  In  one  of  two  cases  in  the 
appended  series,  No.  CCLIV.,  it  followed  profuse  hemor- 
rhage and  was  delayed  till  the  second  day ;  it  was  an  in- 
termittent oozing  for  twenty-four  hours,  amounting  to 
one  drachm  or  more ;  it  was  not  followed  by  serious  effects 
of  brain  injury,  and  the  patient  recovered.  In  the  second 
case  it  was  accompanied  by  profuse  hemorrhage  from  the 
nose  and  mouth,  but  by  none  from  the  ear;  the  patient 
died  in  a  few  hours  and  escaped  necropsic  examination. 
It  is  more  frequently  observed  in  fractures  of  the  vault, 
and  very  rarely  through  the  nose. 

Serous  discharges  from  the  ear  are  also  infrequent.  In 
the  entire  series  of  two  hundred  and  eighty-six  cases  of 
deaths  and  recoveries,  there  are  altogether  thirteen  in- 
stances, but  in  three  it  was  undoubtedly  a  declining  phase 
of  hemorrhage  which  in  each  had  continued  for  a  week, 
gradually  lessening  and  becoming  serous  before  its  cessa- 
tion; and  in  a  fourth,  an  intermittent  sero-sanguinolent 
discharge,  which  appeared  on  the  eighth  or  ninth  day,  was 
clearly  aural  and  inflammatory.  In  the  nine  in  which  it 
was  an  actual  symptom,  it  was  primary  and  independent 
in  two  only,  Nos.  LXXIII.,  CCXXX.,  and  in  one  of  these 


22  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

was  followed  by  recovery.  In  the  recovering  case  it  began 
suddenly  and  very  profusely  a  short  time  after  the  pa- 
tient's fall  from  a  considerable  height,  and  continued  for 
several  days ;  the  development  of  symptoms  of  intracranial 
complication  was  followed  by  a  late  mastoid  inflammation, 
which  was  relieved  by  a  trephination  otherwise  barren  of 
result.  The  second  case,  in  which  the  discharge  was  also 
profuse,  proved  fatal  from  pulmonary  oedema  in  a  few 
hours ;  the  petrous  portion  was  fissured  and  the  brain  ex- 
tensively lacerated  subcortically,  with  only  slight  arachnoid 
hemorrhage  in  the  frontal  region.  The  discharge  in  both 
instances  was  probably  cerebro-spinal,  in  view  of  its  pro- 
fusion and  almost  immediate  occurrence.  In  the  seven 
cases  remaining,  the  serous  fluid,  which  was  abundant  and 
usually  clear,  was  preceded  in  each  by  a  free  hemorrhage 
lasting  from  a  few  hours  to  the  fourth  day ;  three  were  fol- 
lowed by  recovery  and  four  by  death  and  necropsy.  In 
two  of  the  necropsic  cases,  death  was  caused  by  purulent 
meningitis  and  there  had  been  no  intracranial  hemorrhage ; 
in  one  there  was  a  large  arachnoid  serous  effusion  at  the 
base,  and  in  the  other  a  moderate  arachnoid  effusion  with 
excessive  oedema  of  the  brain  substance ;  in  one  the  pos- 
terior surface  of  the  petrous  portion  was  comminuted  and 
in  the  other  a  fissure  traversed  its  central  portion.  In  the 
other  two  necropsic  cases,  petrous  fracture  was  accompanied 
by  large  and  firm  epidural  and  arachnoid  clots  in  a  con- 
tiguous basic  fossa,  and  in  one  of  them  by  thrombosis  of 
the  superior  longitudinal,  lateral,  and  petrosal  sinuses  and 
internal  jugular  vein,  with  a  localized  oedema  in  the  pos- 
terior cerebral  region  confined  to  the  meshes  of  the  pia 
mater.  The  three  recovering  cases  in  which  serous  dis- 
charge followed  hemorrhage  were  not  of  identical  charac- 


PRELIMINARY    CONSIDERATIONS.  23 

ter ;  in  one  it  was  coincident  with  an  extrusion  of  brain 
matter  on  the  second  day  and  continued  twenty-four  hours ; 
in  the  other  two  it  occurred  on  the  second  and  fourth  days 
and  was  of  brief  duration. 

All  the  sources  to  which  these  watery  fluxes  have  been 
ascribed  seem  to  have  been  exemplified  in  these  few  cases. 
In  three  it  was  demonstrably  the  final  phase  of  hemor- 
rhage, and  in  one  the  outcome  of  aural  inflammation ;  in 
two  it  was  no  less  positively  the  cerebro-spinal  fluid,  and 
in  two  an  inflammatory  arachnoid  effusion ;  in  one  at  least 
certainly,  and  in  others  presumably,  it  was  the  result  of  the 
coagulation  of  blood  following  an  intracranial  hemor- 
rhage. In  this  way  it  often  happens  that  exclusive 
theories  are  disproved  by  the  results  of  sufiiciently 
extended  observation. 

The  diagnostic  value  of  watery  discharge  is  very  lim- 
ited ;  if  it  is  primary  and  profuse,  it  is  pathognomonic ;  if, 
as  these  observations  seem  to  show,  it  usually  follows  a 
hemorrhage,  when  it  occurs  at  all,  it  adds  nothing  to  the 
already  assured  certainty  of  fracture. 

Another  and  still  more  infrequent  symptom  of  basic 
fracture  is  an  oedema  of  the  mastoid  region.  In  the  single 
instance  noted,  No.  LXIL,  it  accompanied  fracture  of  the 
posterior  fossa  which  traversed  the  groove  for  the  lateral 
sinus,  with  obstruction  of  that  vessel  by  a  thrombus.  The 
occurrence  of  such  a  symptom  must  necessitate  the  joint 
condition  of  a  venous  obstruction  to  cause  the  oedema  and 
of  a  fracture  to  permit  its  appearance  in  a  cranial  region. 
It  could  hardly  be  apparent  at  any  point  where  the  super- 
ficial tissues  are  thicker  than  those  which  so  thinly  cover 
this  bony  prominence.  In  one  of  the  instances  cited  of 
secondary  serous  discharge  from  the  ear,  it  is  possible  that 


24  INJURIES    OF    THE   BRAIN   AND    MEMBRANES. 

the  same  conjunction  of  thrombosis  and  fracture  may  have 
contributed  to  the  result. 

The  implication  of  a  cranial  nerve  may  discover  the 
existence  of  a  fracture,  even  if  otherwise  unsuspected.  It 
must  be  practicable,  however,  fairly  to  determine  that 
functional  disturbance  or  abeyance  does  not  depend  upon 
intracranial  lesion  before  it  can  be  attributed  to  structural 
injury  of  the  nerve  while  within  its  bony  conduit  or  fora- 
men. It  is  possible  that  any  cranial  nerve  may  be  crushed 
or  compressed  in  this  manner,  though,  with  the  exception 
of  the  second  and  seventh  pairs,  it  is  in  the  highest  degree 
improbable.  In  the  appended  series  of  cases,  there  are 
numerous  instances  in  which  each  in  turn  has  suffered 
functional  loss  or  disturbance  from  intracranial  lesion,  but 
it  is  only  in  case  of  the  second  and  seventh  that  similar 
conditions  have  been  demonstrably  due  to  implication  of 
the  nerve  in  the  line  of  fracture.  The  frequency  with 
which  this  complication  occurs  is  probably  overestimated. 
Facial  paralysis  in  connection  with  head  injuries  is  of  con- 
stant occurrence,  and  fractures  of  the  petrous  portion  in- 
volving the  part  through  which  the  nerve  passes  constitute 
a  large  proportion  of  all  those  extending  into  the  base; 
yet  a  cranial  rather  than  an  intracranial  origin  of  this  con- 
dition is  rarely  suspected,  and  is  still  more  rarely  disclosed 
on  necropsic  examination.  There  is  in  general  neither 
osseous  displacement  nor  retention  of  coagula  to  lacerate 
or  compress  the  nerves,  and  only  one  or  two  examples 
can  be  found  in  the  whole  of  the  appended  series. 

The  lesion  of  the  optic  nerve  at  the  optic  foramen  by 
compression  from  the  osseous  fragments  is  less  exceptional 
than  the  injury  to  the  facial,  and  is  more  readily  discover- 
able, not  only  after  death  but  during  life.     Callan  published 


PRELIMINARY   CONSIDERATIONS.  2$ 

nine  cases  and  has  since  increased  the  number  of  his  obser- 
vations to  seventeen.  The  appended  series  of  cases  in- 
cludes six,  of  which  four  were  recognized  only  upon 
necropsy,  and  of  these  three  had  died  without  the  recovery 
of  consciousness  and  the  fourth  had  suffered  no  loss  of 
vision.  In  one  only  was  the  nerve  implicated  in  the  frac- 
ture. In  the  two  cases  in  which  life  was  preserved,  the 
patient  upon  the  restoration  of  intelligent  consciousness 
discovered  loss  of  vision.  Ophthalmosopic  examination 
made  on  the  third  day  in  the  first  was  negative,  though  the 
pupil  did  not  respond  to  direct  exposure  to  light ;  fifteen 
days  later  atrophy  of  the  optic  nerve  had  begun.  In  the 
second  case  the  ophthalmoscopic  examination  was  not 
made  till  the  fourth  week ;  the  pupil  was  then  insensitive 
to  light  and  atrophy  of  the  nerve  was  in  progress.  Entire 
loss  of  vision  was  permanent  in  both  cases.  These  six 
probably  represent  nearly  if  not  quite  the  whole  number 
of  cranial  injuries  to  the  optic  nerve  in  the  series  of  two 
hundred  and  forty-five  basic  fractures. 

The  necropsic  examinations,  when  the  anterior  fossae 
were  involved,  were  made  with  a  view  to  the  detection  of 
this  complication,  and  if  the  patient  recovered  it  certainly 
could  not  have  escaped  observation  ;  if  there  were  others, 
they  must  have  been  confined  to  the  very  few  instances  in 
which  death  occurred  without  previous  restoration  to  con- 
sciousness, and  in  which  opportunity  was  not  afforded  for 
post-mortem  examination.  The  injuries  to  the  nerve  are 
much  fewer  even  than  the  implications  of  the  optic  fora- 
men in  the  line  of  fracture. 

Callan  gives  this  description  of  the  lesion  and  its  mani- 
festations :  "  It  is  due  to  a  fracture  of  the  sphenoid  bone 
which  compresses  the  optic  nerve  as  it  passes  through  the 


26  INJURIES   OF    THE    BRAIN    AND    MEMBRANES. 

optic  foramen,  and  is  more  likely  to  happen  if  the  blow  is 
received  upon  the  frontal  bone,  but  may  result  from  a  fis- 
sure which  extends  from  another  cranial  region.  Monocu- 
lar blindness  is  immediate  and  generally  with  total  loss  of 
all  light  perception.  The  eyeball  protrudes  and  diverges, 
and  the  pupil  is  enlarged  and  non-responsive  to  light. 
Optic-nerve  atrophy  begins  within  two  weeks." 

The  two  cases  cited  conform  to  this  description,  except 
that  hemorrhage  chanced  to  be  insufficient  to  cause  ocular 
protrusion  or  divergence.  In  only  one  of  the  necropsic 
cases  did  the  fracture  involve  the  sphenoid  body. 

The  cases  in  which  sight  is  destroyed  by  direct  wound 
of  the  orbit,  as  from  pistol  shot  or  by  profuse  hemorrhage 
into  the  orbit  or  globus  oculi  in  fracture  propagated  from 
the  vault,  are  of  less  diagnostic  interest,  because  the  con- 
dition is  obvious  and  readily  apprehended. 

There  is  still  another  and  perhaps  final  direct  symptom 
of  basic  fracture  which  may  suggest  its  existence  and  loca- 
tion in  the  absence  of  more  positive  indications.  It  is  an 
acute  localized  pain,  different  from  the  frontal,  occipital, 
or  diffused  headache  which  is  common  in  all  forms  of  in- 
tracranial lesion.  Its  limitation  and  intensity  serve  to 
distinguish  it  from  the  pain  of  internal  injuries,  while  it  is 
disproportionate  to  the  amount  of  superficial  contusion. 
In  fracture  limited  to  the  posterior  fossa,  in  which  other 
direct  symptoms  are  often  wanting,  it  may  afford  the  only 
ground  for  suspicion,  and  when  it  involves  the  mastoid 
process  its  import  may  be  confirmed  by  the  later  appear- 
ance of  subcutaneous  hemorrhage.  It  has  been  often 
noted  in  the  cases  appended,  and  its  significance  often 
established  in  subsequent  post-mortem  examination. 
This    symptom,    which   has   been    generally   if    not    en- 


PRELIMINARY   CONSIDERATIONS.  2/ 

tirely    overlooked,    is    sufficiently   important    to    deserve 
attention. 

The  evidences  of  intracranial  complication  which  have 
been  so  often  regarded  as  symptoms  of  basic  fracture  are 
indirectly  diagnostic  of  that  lesion,  but  only  in  so  far  as 
they  explain  or  confirm  its  direct  indications ;  they  are  of 
themselves  insufficient,  since  all  of  the  intracranial  lesions 
may  exist  independently,  just  as  fracture  may  occur  with- 
out complication.  The  cranial  and  the  intracranial  lesions, 
however,  concur  in  a  large  majority  of  cases,  and  while  the 
direct  symptoms  are  usually  adequate  to  a  diagnosis  of  the 
fracture,  there  are  still  cases  in  which  an  element  of  doubt 
remains,  to  be  resolved,  possibly,  by  the  recognition  of  an 
internal  injury.  A  profuse  hemorrhage  or  serous  dis- 
charge from  the  ear,  with  certain  restrictions  as  to  the 
conditions  under  which  it  occurs,  or  the  extrusion  of  brain 
tissue,  may  render  the  existence  of  a  petrous  fracture  cer- 
tain ;  but  a  nasal  hemorrhage  or  a  localized  pain,  however 
characteristic,  can  hardly  determine  an  ethmoid  or  sphe- 
noid or  a  mastoid  fracture  with  equal  certainty,  and  con- 
firmation is  naturally  sought  in  the  fact  of  intracranial 
complication.  The  possible  error  in  the  use  of  this  means 
of  diagnosis  has  been  in  ascribing  to  it  undue  importance, 
and  in  a  consequent  depreciation  of  the  value  of  direct 
symptoms.  Some  minor  degree  of  cerebral  contusion  may 
exist  in  any  case  in  which  violence  has  been  sufficient  to 
produce  fracture,  but,  if  so,  its  indications  are  so  often 
slight  and  transitory,  and  early  histories  are  so  often  im- 
perfect, that  this  assumption  is  impossible  of  verification. 
The  presence  therefore  of  even  trivial  intracranial  injury 
cannot  be  regarded  as  essential  and  much  less  as  of  pri- 
mary importance  in  the  diagnosis  of  fracture,  which  really 


28  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

occurs  much  oftener  without   complication  than  without 
the  evidence  of  direct  symptoms. 

Fractures  of  the  base  were  for  a  long  time  regarded  as 
shrouded  in  mystery,  and,  like  the  intracranial  traumata, 
as  problems  to  be  satisfactorily  solved  only  by  necropsic 
examination.  The  means  afforded  for  their  diagnosis  are 
certainly  not  unusually  restricted ;  the  possibility  of  trac- 
ing the  fissure  from  its  origin  in  the  vault,  the  evidence  of 
external  hemorrhages,  serous  discharges,  or  extrusions  of 
brain  tissue,  the  localization  of  pain,  and  the  concurrence 
of  complicating  intracranial  lesions,  suffice  in  by  far  the 
larger  number  of  cases  to  remove  them  from  the  domain 
of  obscurity  and  conjecture. 

Prognosis. 

The  prognosis  of  cranial  fracture  demands  some  con- 
sideration. It  concerns  repair,  the  loss  of  function,  and 
by  a  possibility  the  danger  to  life. 

The  restoration  of  the  bone  in  simple  linear  fracture  is 
effected  by  a  definitive  callus  and  is  perfect ;  even  a  trace 
of  its  existence  is  eventually  discoverable  in  only  the  most 
exceptional  instances.  At  the  base,  in  which  fracture  is 
almost  invariably  of  this  form  when  propagated  from  the 
vault,  and  in  which  frequency  of  occurrence  and  of  recov- 
ery would  presuppose  frequency  of  disclosure  in  the  dead- 
house  if  evidence  of  closed  fissures  remained,  it  is  practi- 
cally unknown  as  an  ancient  lesion.  A  cranium  discovered 
and  lost  in  the  morgue  of  Bellevue  Hospital  many  years 
ago,  by  a  youth  ignorant  of  its  pathological  value,  exhibited 
a  line  of  fracture  across  both  middle  fossae  with  slight  dis- 
placement  of   the   posterior   segment   upward,   and   with 


PRELIMINARY    CONSIDERATIONS.  29 

union  long  perfected.  This  specimen  was  periiaps  uniqiie. 
If  the  fissure  is  widely  opened  and  the  patient  survives  the 
complications  with  which  it  is  likely  to  be  attended,  it  will 
be  approximately  closed  by  the  elasticity  of  the  skull  be- 
fore repair  begins.  In  any  event  the  process  is  slow  and 
may  extend  over  many  months.  An  exception  to  the 
almost  invariable  closure  of  an  open  fissure  occurs  in  one 
of  the  appended  cases,  in  which,  with  a  fracture  through 
the  median  line  of  the  frontal  bone  extending  into  an  orbi- 
tal plate,  perceptible  separation  and  mobility  of  the  seg- 
ments existed  five  years  after  a  comminution  of  the  vertex. 
The  very  unusual  instances  cited,  the  displacement  of  seg- 
ments of  the  base  and  the  lack  of  union  in  fissure  of  the 
vault,  are  merely  curiosities  of  surgical  experience.  The 
established  rule  as  to  the  absence  of  displacement  and  the 
perfection  of  union  in  this  class  and  variety  of  cranial  frac- 
tures is  unaffected.  Fracture  of  the  orbital  processes  of 
the  frontal  bone  occur  under  special  conditions,  and  dis- 
placement of  fragments  which  sometimes  directly  lacerate 
the  frontal  lobes  are  not  uncommon ;  they  are  consequently 
allied  to  fractures  of  the  vault  rather  than  of  the  base. 
The  only  dangers  directly  attributable  to  linear  fracture 
are  essentially  confined  to  the  orbital  region,  and  are  the 
laceration  of  the  brain  by  elevation  of  an  orbital  fragment 
and  implication  of  the  optic  nerve  in  its  foramen  of  exit. 
Displacement  elsewhere  in  the  base  or  in  the  vault  Avithout 
comminution  is  practically  impossible ;  implication  of  other 
cranial  nerves  is  very  exceptional,  and  no  subsequent  harm 
can  come  from  the  simple  process  of  repair.  Depressed  or 
displaced,  and  comminuted,  fractures  are  limited  to  the 
vault  and  orbit,  regions  in  which  the  bone  is  comparatively 
thin,  and  are  often  prolonged  by  simple  fissures.     If  the 


30  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

bone  is  composed  of  two  tables,  depression  may  be  con- 
fined to  either,  and  if  the  inner  be  the  one  depressed,  the 
outer  is  usually  but  not  invariably  fissured ;  and  if  both 
are  depressed,  the  inner  is  likely  to  be  the  more  exten- 
sively involved  and  often  comminuted.  These  simple 
facts  are  of  common  acceptance.  If  the  displaced  frag- 
ments can  be  restored  to  their  normal  position  without  loss 
of  substance,  the  lines  of  fracture  only  remain  and  will 
unite  as  readily  and  with  as  little  incidental  danger  as 
primitive  fissures.  If  loss  of  substance  results  from  the 
displacement  and  necessary  removal  of  fragments,  the  un- 
aided osteogenic  properties  of  the  pericranium,  diploe,  and 
dura  are  insufficient  to  replace  the  portion  which  is  lost. 
The  dense  fibrous  structures  which  then  occupy  the  osse- 
ous hiatus  imperfectly  protect  the  cranial  contents  from 
external  violence,  and  this  structural  weakness  is  a  source 
of  danger  proportionate  to  the  extent  and  situation  of  the 
enfeebled  part.  The  detached  fragments,  when  com- 
pletely separated  and  depressed,  may  become  the  source 
of  additional  dangers ;  they  may  be  encapsulated  in  the 
dura  and  by  irritative  pressure  lead  to  remote  neuro-psy- 
chic  disturbances,  or  they  may  be  necrosed  and  occasion 
dural  or  peripheral  abscess. 

The  complications  of  depressed  fracture  are  twofold: 
there  are  concomitant  intracranial  lesions,  as  general  me- 
ningeal or  cerebral  contusions  or  distant  lacerations  pro- 
duced simultaneously  by  the  same  violence  which  causes 
the  fracture,  and  common  to  all  its  varieties;  and  there 
are  superadded  the  localized  wounds  inflicted  by  the  dislo- 
cated fragments.  The  coincident  injuries  have  no  part  in 
the  prognosis  of  fracture ;  the  consecutive  lesions  consti- 
tute whatever  elements  of  danger  it  possesses.     Hence  a 


PRELIMIXARY    CONSIDERATIONS.  3 1 

seeming  paradox.  The  fissured  fracture  of  the  base  is 
often  followed  by  a  fatal  result,  while  the  depressed  and 
comminuted  fractures  of  the  vault  generally  end  in  recov- 
ery. The  harmless  fissure  of  the  base  is  likely  to  be  asso- 
ciated with  grave  concomitant  lesions,  and  being  in  bad 
company  is  held  responsible  for  the  fatalities  to  which 
these  complications  directly  lead ;  the  more  dangerous 
fractures  characteristic  of  the  vertex  are  oftener  compli- 
cated only  by  the  direct  and  accessible  injuries  of  their 
own  production.  The  coincident  lesions  are  in  a  majority 
of  instances  beyond  remedy,  though  not  equally  beyond 
recovery ;  the  consecutive  injuries  are  in  larger  proportion 
amenable  to  treatment.  In  a  minority  of  cases  a  wound  of 
a  dural  sinus  or  of  the  middle  meningeal  artery  may  be 
irremediable,  or  a  cerebral  laceration  made  by  an  orbital 
fragment  may  be  inacccessible,  and  it  is  possible  that 
structural  disorganization  from  crushing  violence  may  be 
irreparable;  but  ordinarily  the  hemorrhages  and  lacera- 
tions at  the  site  of  fracture  are  manageable  and  infection 
is  preventible  if  surgical  interference  is  sufficiently  early 
and  complete. 

It  is  therefore  true  that  in  themselves  cranial  fractures 
are  important  only  in  exceptional  cases.  Their  prognosis 
is  really  the  prognosis  of  their  complications.  Neither 
the  shock  of  an  uncomplicated  fracture  nor  the  hemor- 
rhage from  the  osteal  vessels  is  ever  fatal.  Its  methods  of 
repair  involve  no  subsequent  dangers,  and  if  it  occasions 
loss  of  substance  which  necessarily  fails  of  osteogenetic 
restoration  it  can  only  increase  a  bare  chance  of  remote 
disaster  from  some  future  exposure  to  violence.  The 
fatalities  which  follow  in  its  train  are  in  the  vast  majority 
of  cases  due  to  concomitant  lesions  with  which  it  has  only 


32  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

an  accidental  and  innocent  connection.  The  consecutive 
complications  for  which  alone  it  is  responsible  are  usually 
amenable  to  control,  and  there  remains  only  a  residuum  of 
scattered  cases  beyond  the  pale  of  relief  to  justify  its  evil 
reputation. 

The  tabulation  of  cases  of  fractured  base  or  vault,  with 
reference  to  the  percentage  of  recoveries  or  its  relation  to 
the  region  involved,  is  useless,  except  it  be  to  determine 
the  probability  of  a  fatal  complication,  or  its  more  frequent 
occurrence  in  different  parts.  The  fracture  is  rarely  more 
than  an  incident.  The  generalization  supposed  to  be  jus- 
tified by  the  discovery  that  in  a  certain  number  of  cases  of 
fractured  base  recovery  followed  in  all  in  which  injury 
was  survived  for  twenty-four  hours,  is  a  familiar  illustra- 
tion of  the  idleness  of  purely  arithmetical  conclusions.  It 
is  well  known  that  the  issue  of  coincident  intracranial  le- 
sions is  not  usually  determined  in  that  length  of  time.  An 
analysis  of  the  results  and  conditions  of  fractures  included 
in  the  appended  series  of  cases  will  show  a  fatality  in 
nearly  two-thirds  of  those  which  involved  the  base  and 
about  one-third  of  those  which  were  confined  to  the  vault, 
but  in  the  total  of  three  hundred  and  fifty  there  are  less 
than  a  score  in  which  the  fracture  was  the  determining 
cause  of  death. 

Treatment. 

The  treatment  of  cranial  fracture  is  essentially  local. 
If  the  osseous  lesion  is  devoid  of  intracranial  complication, 
there  will  be  no  general  indications  to  meet,  and  if  com- 
plicated, the  general  treatment  will  not  be  modified  by  the 
coexistence  of  fracture.  The  initiative  of  treatment  in  the 
presence    of    grave    complication   will    be    constitutional. 


PRELIMINARY    CONSIDERATIONS.  33 

Shock  is  the  most  urgent  primary  condition,  and  until  re- 
action has  been  established,  no  local  interference  is  per- 
missible except  it  be  for  the  control  of  hemorrhage  by  the 
simplest  possible  means.  If  the  hemorrhage  is  serious  it 
may  be  proper  to  go  farther,  even  to  the  extent  of  invad- 
ing the  cranial  cavity,  since  in  emergencies  even  laws  are 
held  in  abeyance — but  always  with  discretion.  The  gen- 
eral principle  that  the  resort  to  local  measures  must  await 
the  restoration  of  nervous  and  vascular  force,  except  for 
the  relief  of  hemorrhage  by  which  depression  is  prolonged, 
is  a  fundamental  law  in  surgery.  The  neglect  of  this  pre- 
cept is  one  of  the  most  frequent  errors  of  inexperienced 
practitioners  and  hospital  assistants,  and  seems  especially 
to  prevail  in  the  case  of  injuries  of  the  head;  that  life 
is  often  thus  jeopardized  or  sacrificed  at  the  outset  is  mani- 
fest not  only  from  observation  but  in  the  published  his- 
tories of  cases.  In  the  absence  of  shock  or  after  reaction 
has  been  secured,  the  injury  should  receive  immediate 
attention.  If  operative  measures  prove  to  be  required, 
early  conditions  are  more  favorable  than  those  presented 
after  pathic  changes  have  begun.  The  principles  of  sur- 
gical procedure  are  precisely  the  same  as  with  complicated 
fractures  of  the  extremities :  the  establishment  of  reaction 
and  then,  if  interference  be  demanded,  a  resort  to  primary 
rather  than  to  secondary  operation. 

Fractures  of  the  base  rarely  admit  of  direct  interfer- 
ence, even  for  exploration.  They  are  usually  inaccessible, 
and  of  the  linear  type  which  neither  involves  danger  nor 
requires  rectification ;  it  is  only  incidentally  in  an  exami- 
nation of  a  fracture  of  the  vault  from  which  it  takes  its 
origin  that  a  basic  fissure  may  be  justifiably  exposed  for 
inspection. 
3 


34  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

If  a  petrous  fracture  has  been  made  compound  by  its 
implication  of  the  internal  auditory  passage  and  a  rupture 
of  the  tympanum,  though  the  danger  of  infection  may  be 
slight,  it  should  be  repelled  by  careful  aseptic  protection 
of  the  external  meatus.  A  similar  external  communi- 
cation of  an  ethmoid  or  a  sphenoid  fracture  through  the 
nasal  cavities  is  anatomically  less  favorably  situated  for 
the  exercise  of  aseptic  precautions.  Fractures  of  the  orbit 
or  of  the  ethmoid  bone,  the  result  of  immediate  violence, 
are  allied  to  fractures  of  the  vault  not  only  in  character 
and  prognosis  but  in  treatment ;  and  the  replacement  or 
removal  of  osseous  fragments  and  the  observance  of  asep- 
tic care  in  the  management  of  the  osseous  wound  may  be- 
come practicable  and,  if  so,  are  no  less  imperative. 

The  requirements  of  treatment  in  the  case  of  fracture 
of  the  vault  are  more  positive.  There  are  simple  uncom- 
plicated fissures  which  are  often  undiscovered  and  always 
unimportant,  and  which  are  better  left  without  interfer- 
ence; but  complicated  fissures  and  comminuted,  depressed, 
and  punctured  fractures,  even  without  apparent  complica- 
tion, demand  complete  exploration,  operative  reduction  to 
their  simplest  possible  form,  and  rigid  aseptic  methods  in 
the  immediate  and  subsequent  treatment  of  the  wound. 
These  conditions  are  absolute,  and  the  particular  measures 
which  they  necessitate  are  immaterial,  but  should  be  as 
simple  as  is  compatible  with  the  attainment  of  the  ends  in 
view.  It  is  useless  to  discuss  the  propriety  of  one  method 
of  procedure,  or  the  safety  of  another ;  it  is  the  necessity 
of  either  to  the  fulfilment  of  essential  indications  which 
must  be  brought  in  question.  Everything  is  proper  which 
is  indispensable,  and  anything  is  safe  which  can  be  pos- 
sibly required  for  the  better  comprehension  and  treatment 


PRELIMINARY    CONSIDERATIONS.  35 

of  this  very  simple  form  of  injury.  If  therefore  the  exist- 
ence of  a  hidden  fracture  of  the  vault  can  be  ascertained 
by  palpation,  incision  should  be  practised  in  order  to  de- 
termine its  extent  and  characters;  even  a  doubt  in  the 
presence  of  intracranial  complication  should  be  resolved 
by  making  direct  inspection  possible.  If  the  cranial  sur- 
face is  precluded  from  digital  examination  by  a  large  or 
well-defined  haematoma,  incision  should  still  be  made, 
though  as  yet  there  may  be  no  indicaton  of  internal  injury. 
So  far  diagnosis  and  treatment  coincide.  This  method  is 
justified  not  only  by  the  necessity  of  exploration  for  the 
intelligent  determination  of  treatment,  but  both  by  theo- 
retical considerations  of  safety  and  by  the  results  of  experi- 
ence. It  has  no  conceivable  dangers;  the  matter  of  infec- 
tion is  within  the  control  of  the  surgeon,  and  the  amount 
of  additional  shock  or  hemorrhage  involved  in  an  explora- 
tive incision  is  inappreciable.  This  course  has  been  gen- 
erally pursued  in  the  conduct  of  cases  in  the  series 
appended,  and  the  issue  has  confirmed  the  opinion  ex- 
pressed as  to  its  propriety.  The  absence  of  shock,  a  fair 
constitutional  condition,  and  the  observance  of  ordinary 
precautions;  the  maintenance  of  asepsis,  the  careful  re- 
pression of  hemorrhage,  and  the  restriction  of  the  wound 
to  the  limits  required  for  its  purpose,  are  always  to  be 
assumed. 

If  the  incision  reveals  no  fracture,  or  a  fine  fissure 
which  is  deemed  unimportant,  the  wound  can  be  closed 
and  the  patient  will  be  none  the  worse  for  the  means  taken 
to  ascertain  the  nature  and  extent  of  his  local  injury ;  but 
if  a  more  pretentious  fissure  or  some  other  form  of  frac- 
ture is  disclosed,  exploration  and  treatment,  still  conjoined, 
must  be  farther  extended.     The  depressed  fracture  may 


36  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

be  said  to  include  all  the  others,  since  it  is  the  possibility 
of  concealed  depression  which  gives  importance  to  cranial 
comminution  or  puncture,  and  removes  the  first  from  the 
class  of  mere  multiple  fissure,  or  the  second  from  the  con- 
dition of  a  wound  left  by  trephination.  It  is  the  continued 
uncertainty  as  to  the  amount  of  injury  done  to  the  internal 
table  which  compels  further  exploration,  even  at  the  cost 
of  operation  when  the  external  depression  may  seem  un- 
important. The  extensive  and  entirely  disproportionate 
comminution  of  the  internal  table  and  the  frequent  serious 
laceration  of  the  brain  by  its  dislocated  fragments,  with 
simple  fissure  or  trivial  external  depression,  have  been 
made  notorious  by  reiteration  and  illustration  in  every 
surgical  text-book.  These  conditions  often  are  suggested 
by  no  primar}^  general  symptoms  of  complication,  and,  if 
unsought,  must  remain  undiscovered  at  the  peril  of  the 
patient.  The  unfortunate  results  of  such  neglected  frac- 
tures have  forced  themselves  upon  the  attention  of  every 
surgeon ;  immediate  septic  infection  or  remoter  effects  of 
cerebral  irritation  or  pressure  from  completely  severed  or 
partially  detached  osseous  fragments  resting  upon  or  pene- 
trating the  brain,  including  dural  or  cortical  abscess,  cere- 
bral necrosis,  epileptiform  convulsions,  and  multiform 
disturbances  of  functional  control,  have  not  yet  ceased  to 
be  of  common  occurrence,  though  with  improvement  of 
practice  they  have  notably  diminished  in  frequency.  Forty 
years  ago,  Dr.  James  R.  Wood,  who  was  often  in  advance 
of  his  time,  was  the  only  surgeon  of  eminence  who  taught 
the  necessity  of  elevating  depressed  bone  under  all  circum- 
stances when  not  specifically  contraindicated.  Since  then 
Roberts,  Nancrede,  and  other  still  more  recent  writers 
have  advocated  it  as  a  general  rule  of  treatment.     The  in- 


PRELIMINARY    CONSIDERATIONS.  37 

junction  to  refrain  from  interference  with  depressed  frac- 
tures in  the  absence  of  complicating  symptoms,  however, 
is  still  widely  upheld  and  respected  in  the  profession,  for 
no  better  apparent  reason  than  the  fact  that  many  patients 
who  are  treated  upon  the  expectant  plan  at  least  tempo- 
rarily recover,  notwithstanding  the  recognized  dangers  to 
which  they  are  exposed.  The  influence  of  tradition  and  a 
failure  to  apprehend  the  changed  conditions  of  modern 
surgery  often  content  the  general  practitioner  v/ith  the 
gambler's  chance,  and  the  patient  takes  all  the  risk. 

There  may  be  a  slightly  wider  latitude  of  opinion  allow- 
able when  the  bone  is  not  obviously  depressed,  but  the 
probabilities  of  depression  when  the  vault  is  comminuted 
or  traversed  by  an  open  fissure,  or  when  the  fracture  is  of 
the  punctured  variety,  are  sufficient  to  warrant  a  positive 
solution  of  the  question  when  it  arises.  A  comminution 
indicates  great  violence,  limited  or  diffused,  or  else  struc- 
tural weakness  of  the  bone,  and  in  either  case  makes  prob- 
able greater  injury  of  its  deeper  part  than  is  apparent  upon 
the  surface.  A  punctured  fracture  almost  invariably  in- 
volves concealed  injury  of  which  the  external  lesion  affords 
no  means  of  estimate.  The  exposure  of  the  inner  table  in 
both  varieties  is  essential  to  safety,  and  should  be  made, 
almost  without  exception,  when  the  general  condition  of 
the  patient  permits.  There  are  sometimes  numerous  fine 
fissures,  perhaps  radiating  from  a  point  of  impact,  without 
mobility  of  the  intervening  parts,  and  the  case  is  then  to 
be  regarded  as  one  of  multiple  fissure  rather  than  of  com- 
minution. The  proper  course  to  pursue  in  the  case  of  a 
fissure  may  in  some  instances  seem  difficult  to  decide ;  it 
is  plain  enough  when  the  fissure  is  insignificant,  appar- 
entlv  limited  to  the  outer  table,  and  has  been  made  com- 


38  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

pound  only  by  incision,  or,  conversely,  when  it  is  wide  and 
deep,  and  exposed  by  primary  injury.  The  only  rule 
which  can  be  formulated  is  that  hesitation  is  always  to  be 
ended  by  sufficient  exploration  to  resolve  whatever  doubt 
exists.  If  the  fissure  is  originally  compound,  its  danger 
is  enhanced  by  the  possibility  that  infection  has  already 
occurred,  since  it  is  well  known  that  even  closed  fissures 
may  have  been  open  in  their  inception.  The  concurrence 
of  symptoms  of  intracranial  injury  gives  additional  force 
to  the  direct  indications  for  deep  exploration,  by  increas- 
ing the  probability  that  the  hurt  has  been  sufficiently 
severe  to  comminute  the  inner  table. 

The  exploration  and  rectification  of  a  fracture,  of  what- 
ever character,  can  ordinarily  be  effected  by  very  simple 
operative  measures,  and  by  the  use  of  correspondingly 
simple  instruments.  Depressed  bone  in  a  large  propor- 
tion of  cases  can  be  raised  by  the  periosteal  elevator,  the 
cranial  opening  can  be  sufficiently  enlarged  by  the  ron- 
geur, osseous  fragments  can  be  removed  by  any  kind  of 
forceps,  and  intracranial  exploration  made  by  the  ordinary 
probe.  If  the  elevator  cannot  be  inserted,  a  sufficient 
opening  can  often  be  obtained  with  the  burr  drill.  The 
use  of  the  trephine  is  only  occasionally  required.  Com- 
minuted fractures  may  be  exposed  and  fragments  removed 
with  equal  facility  and  by  the  aid  of  the  same  instruments. 
Even  punctured  wounds  of  the  cranium  may  sometimes  be 
enlarged  by  the  rongeur.  There  is  no  objection  to  the 
resort  to  the  trephine  in  any  case  in  which  it  better  or 
more  conveniently  serves  the  purposes  of  the  opera- 
tion. The  chisel  is  best  adapted  to  the  examination 
of  fissures  and  can  be  supplemented  by  the  trephine  if 
reason  is  found  to  suspect    internal  comminution.      The 


PRELIMINARY    CONSIDERATIONS.  39 

details   of    procedure    are    exemplified    in    text-books    of 
general  surgery. 

Trephination  has  been  voluminously  discussed,  and 
large  tabulations  have  been  made  of  cases  in  which  it  has 
been  a  feature  in  treatment.  Whatever  of  propriety  or 
necessity  may  have  existed  heretofore  for  the  marked 
attention  which  has  been  accorded  this  simple  operative 
procedure,  or  whatever  question  may  still  exist  as  to  its 
employment  in  the  treatment  of  intracranial  lesions,  there 
can  be  no  longer  reason  to  give  it  special  prominence  or  to 
individualize  it  among  the  other  expedients  utilized  in  the 
management  of  fractures.  It  is  simply  an  incident  in 
treatment,  to  be  used  or  avoided  as  the  exigencies  of  a  case 
may  suggest,  not  dangerous  in  itself,  and  no  more  respon- 
sible for  the  outcome  than  the  choice  of  a  knife  for  mak- 
ing the  incision  or  of  a  forceps  for  the  extraction  of  an 
osseous  fragment.  The  statistical  tables  which  have  de- 
termined the  rate  of  mortality  in  cases  in  which  trephina- 
tion has  been  employed  have  also  shown  the  infrequency 
with  which  the  operation  has  contributed  to  the  fatal  re- 
sults recorded.  It  is  the  complication  which  kills,  not  the 
fracture,  nor  the  means  of  treatment  which  the  fracture 
requires.  The  percentage  of  deaths  for  which  it  is  held 
responsible,  three  per  cent.  (Amidon),  is,  in  view  of  the 
fallibility  of  human  judgment  and  the  natural  errors  of 
inexperience,  rather  remarkable.  It  seems  probable  in  the 
exceptional  cases  in  which  operation,  whether  trephination 
or  some  other  procedure,  and  not  the  lesion,  is  justly 
chargeable  with  the  death  which  follows,  that  the  timidity 
or  recklessness  of  the  operator  is  likely  to  be  in  fault — a 
timidity  which  allows  the  case  to  drift  till  the  development 
of  symptoms  compels  interference  under  unfavorable  cir- 


40  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

cumstances,  or  a  recklessness  which  impels  to  operation 
regardless  of  the  constitutional  condition  of  the  patient. 
There  is  no  apparent  reason  why  trephination  should  in- 
volve peculiar  dangers;  it  is  not  an  operation  in  which 
shock  need  be  excessive,  nor  in  which  a  general  anaes- 
thetic even  need  be  employed  if  deemed  unadvisable,  or 
in  which  the  danger  of  infection,  whether  from  exposure 
of  the  diploe  or  of  the  cranial  cavity  need  be  greater  than 
in  the  making  of  the  external  incision,  if  it  need  exist  at 
all.  The  consideration  of  treatment  in  general  has  been 
advanced  to  a  higher  plane  than  it  formerly  occupied,  and 
the  proper  fulfilment  of  indications  has  become  of  greater 
recognized  importance  than  the  selection  of  means  for 
their  accomplishment.  It  suffices  if  these  are  as  simple  as 
may  be  and  devoid  of  unnecessary  danger.  Greater  dis- 
crimination is  also  exercised  in  estimating  the  results  of 
necessarily  fatal  injuries,  and  the  effects  of  possibly  un- 
successful measures  taken  for  their  relief.  It  is  now 
recognized  that  trephination  is  in  itself  neither  a  formi- 
dable procedure  nor  necessarily  of  radical  importance,  and 
it  has  therefore  come  to  be  regarded  as  a  less  prominent 
factor  in  the  prognosis  and  treatment  of  injuries  of  the 
head. 

The  differentiation  of  cranial  fracture  from  complicat- 
ing intracranial  lesion  defines  the  limit  within  which  op- 
erations for  its  rectification  are  imdertaken.  They  may  be 
primarily  explorative,  but  are  ultimately  prophylactic  and 
not  curative.  The  fracture  of  the  bone  is  not  directly  a 
source  of  danger,  but  the  lesions  of  the  brain  and  me- 
ninges which  its  dislocated  fragments,  unless  reduced  or 
removed,  may  produce  often  lead  to  immediate  or  remote 
disaster.     The  traditional  cases  in  which,  by  the  elevation 


PRELIMINARY    CONSIDERATIONS.  41 

of  a  depressed  fragment  of  bone  and  relief  of  "  compres- 
sion," the  patient  in  the  twinkling  of  an  eye  springs  from 
profound  coma  into  consciousness  and  mental  activity, 
seem  to  be  extinct.  Instances  still  occur  in  which  by  the 
opening  of  the  cranial  cavity  and  incidental  elevation  of 
encroaching  bone  for  the  relief  of  intracranial  hemorrhage 
and  removal  of  coagula,  cerebral  function  is  presently  re- 
stored ;  but  these  operations  concern  the  treatment  of  con- 
secutive complication. 


chapter    I. 

PATHOLOGY. 

DIRECT    LESIONS. 

The  traumatic  intracranial  lesions,  whether  they  occur 
independently  or  as  complications  or  sequelae  of  cranial 
fracture,  cannot  be  predicated  upon  the  amount  of  violence 
apparently  inflicted.  Injuries  received  by  falls  upon  the 
head  from  great  distances,  or  from  a  mere  stumble  upon 
the  street,  may  be  in  either  event  trivial  or  disastrous; 
force  in  the  one  case  may  be  so  broken  in  various  ways 
that  its  final  impact  is  minimized,  as  in  the  other  it  may 
be  fully  conserved  or  even  exaggerated  by  attendant  con- 
ditions. Their  exact  history  is  rarely  attainable.  The 
effect  of  a  glancing  blow  differs  from  that  of  one  which  is 
direct,  and  the  comparative  elasticity,  thickness,  or  density 
of  the  skull  will  modify  the  extent  and  character  of  intra- 
cranial injuries  as  well  as  of  fracture.  The  study  there- 
fore of  different  forms  of  violence,  in  the  necessary  absence 
of  essential  data,  is  of  no  practical  utility. 

The  intracranial  traumatic  lesions  may  be  classified 
primarily  as: 

Hemorrhages. 

Thromboses  of  sinuses. 

Contusions. 

Lacerations. 

And  their  sequelae  as : 

Meningeal  and  parenchymatous  inflammations,  which 
are  usually,  if  not  invariably,  of  a  septic  character;  and 


PATHOLOGY.  43 

Atrophy. 

The  primary  conditions  may  occur  as  isolated  lesions 
or  in  combination  with  each  other,  and  the  later  inflamma- 
tions which  may  also  coexist  develop  at  any  period  during 
the  persistence  of  the  direct  structural  changes  upon  which 
they  in  part  depend. 

The  hemorrhages  may  be  epidural,  pial,  cortical,  or 
parenchymatous,  and  the  contusions  and  lacerations  may 
either  be  confined  to  the  brain  or  meninges  or  may  involve 
both  structures  with  a  predominance  in  one. 

As  previously  stated,  when  the  intracranial  lesions 
occur  as  complications  of  fracture  they  may  be  coincident 
or  consecutive,  and  usually  dominate  the  symptomatology, 
afford  the  indications  for  treatment,  and  determine  the 
prognosis  of  the  case. 

I.  Hemorrhages. 

Some  confusion  has  arisen  in  the  nomenclature  of  hem- 
orrhages as  it  relates  to  their  nature  and  location.  The 
use  of  the  term  "epidural"  is  anatomically  correct,  and  as 
the  sources  of  this  hemorrhage  are  various  it  would  be 
doubtless  difficult  or  impossible  to  suggest  another  which 
would  at  the  same  time  denote  its  origin.  The  terms 
"subdural"  and  "arachnoid"  are  indefinite  as  to  location, 
and  imply  nothing  as  to  source,  and  are  therefore  objec- 
tionable. These  deeper  hemorrhages  are  derived  from 
the  vessels  of  the  pia  mater  and  from  or  through  the  cere- 
bral cortex,  and  are  always  originally  situated  beneath  the 
visceral  arachnoid  membrane,  though  if  the  extravasation 
is  sufficiently  large  it  will  secondarily  break  through  into 
the  arachnoid  cavity.     This  extension  has  no  clinical  or 


44  INJURIES    OF   THE   BRAIN   AND    MEMBRANES, 

Other  importance,  but  to  specialize  them  as  subarachnoid 
rather  than  as  subdural  would  somewhat  more  closely  de- 
fine their  anatomical  position.  The  designations  "pial" 
and  "cortical,"  as  the  subarachnoid  hemorrhage  is  of  me- 
ningeal or  visceral  origin,  are  topographically  exact  and 
pathologically  distinctive.  If  the  prefix  epidural  is  invari- 
ably used  to  characterize  a  hemorrhage  which  separates 
the  dura  from  the  cranial  wall,  "pial,"  to  characterize  a 
hemorrhage  into  that  membrane  from  rupture  of  its  ves- 
sels, and  "cortical"  to  characterize  a  hemorrhage  upon  the 
surface  of  the  brain  from  laceration  of  its  substance,  both 
the  source  and  location  of  the  hemorrhage  will  be  ex- 
pressed in  a  single  word  with  accuracy  and  conciseness, 
and  the  description  of  cases  much  shortened  and  fa- 
cilitated. 

a.  Epidural  hemorrhage,  when  derived  from  the  diploic 
vessels,  is  usually  inconsiderable  in  amount,  and  may  ap- 
pear externally  beneath  the  pericranium  and  in  the  situa- 
tions noted  in  connection  with  basic  fractures.  If  it  escape 
from  the  cranial  cavity,  its  importancce  in  this  form  is 
mainly  diagnostic,  and  if  retained,  is  insufficient  to  occa- 
sion symptoms ;  but  in  exceptional  instances  of  compound 
fracture  of  the  vertex  the  loss  of  blood  from  this  source 
has  been  excessive.  The  implication  of  the  dural  vessels 
increases  the  extent  of  hemorrhage  in  proportion  to  their 
size,  and  in  case  the  arteria  meningea  media  or  either  of 
its  primary  branches  is  involved  the  danger  to  life  be- 
comes imminent.  The  effusion  from  these  large  menin- 
geal vessels  is  usually  rapid,  with  early  coagulation,  and 
may  be  as  much  as  six  or  eight  fluid  ounces  in  volume. 
The  lateral  aspect  of  the  corresponding  cerebrum  is  some- 
times converted  by  compression  into  an  oblique  plane,  and 


PATHOLOGY.  45 

with  the  dura  may  remain  for  a  time  after  the  removal  of 
the  clot  widely  separated  from  the  bone,  both  laterally  and 
at  the  base.  In  one  of  the  appended  recovering  cases  the 
clot  from  a  smaller  meningeal  branch  in  the  squamous 
region  measured  four  fluid  ounces,  and  was  one  and  a  half 
inches  in  thickness  in  its  central  portion.  The  laceration 
may  be  occasioned  by  a  wound  inflicted  by  a  fragment  of 
the  inner  table,  by  rupture  in  the  line  of  fracture,  or  by 
contrecoup,  and  may  even  occur  without  cranial  lesion. 
These  different  forms  of  injury  are  all  exemplified  in  the 
two  hundred  and  twenty-five  necropsic  cases  included  in 
the  appended  series.  The  dural  sinuses  are  a  further 
vsource  of  large  hemorrhages,  possibly  from  direct  rupture 
of  their  walls  but  more  generally  from  wound  by  an  osse- 
ous fragment.  The  accumulation  of  coagula  is  less  than 
in  the  meningeal  variety,  since  the  fragment  which  causes 
the  injury  so  often  closes  it  till  disturbed  by  manipulation. 
The  profuse  discharge  of  dark-colored  fluid  blood  which 
at  once  follows  the  elevation  or  removal  of  a  portion  of 
bone  from  the  vicinity  of  a  sinus  readily  indicates  the 
nature  of  the  lesion.  The  greater  longitudinal  sinus  is 
the  one  usually  involved  and  is  not  infrequently  lacerated 
in  fractures  of  the  vertex.  The  lateral  sinus  is  occasion- 
ally wounded,  but  from  its  situation  is  somewhat  more 
subject  to  rupture  from  transmitted  force.  The  hemor- 
rhage is  less  manageable  than  that  from  the  longitudinal 
sinus  and  is  a  far  more  serious  accident.  The  wounding 
or  rupture  of  the  other  sinuses  must  be  of  exceeding  rarity 
except  as  it  occurs  in  connection  with  crushing  or  disorga- 
nizing injuries  in  which  all  the  adjacent  structures  are 
concerned. 

The   several   species  of  epidural  hemorrhage   may  be 


46  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

variously  commingled,  but  it  is  likely  to  be  essentially  of 
one  distinguishable  and  predominating  character, 

b.  Pial  hemorrhage  is  occasioned  by  rupture  of  the 
vessels  of  the  pia  mater  and  is  primarily  confined  to  its 
meshes.  It  is  one  of  the  results  of  intracranial  contusion 
and  is  independent  of  epidural  extravasation.  In  its  sim- 
plest form  it  consists  of  punctate  extravasations  analogous 
to  those  which  occur  in  the  brain  substance.  It  more 
characteristically  forms  a  thin  sheet  over  the  vertex ;  if  it 
is  in  larger  quantity  it  breaks  into  the  arachnoid  cavity,  or 
less  probably  dissects  the  pia  mater  from  the  cerebral  sur- 
face. It  may  be  universal  or  it  may  occur  in  patches,  pos- 
sibly a  single  one  of  not  more  than  one  inch  in  diameter, 
or  perhaps  covering  the  vertex  upon  one  or  both  hemis- 
pheres. The  quantity  of  blood  effused  is  never  so  great 
as  it  may  be  in  epidural  hemorrhage,  and  its  clinical  im- 
portance is  mainly  due  to  its  association  with  other  lesions. 
There  are  still  cases  in  which  it  is  large  enough  not  only 
to  occasion  symptoms  of  general  and  local  pressure  but 
to  destroy  or  endanger  life. 

c.  Cortical  hemorrhage  is  the  direct  result  of  a  wound 
of  the  brain  substance,  which  may  be  superficial,  or  may 
be  subcortical  with  an  access  of  blood  to  the  surface  by 
rupture  of  the  intervening  tissue.  It  varies  in  extent  from 
a  trivial  oozing  which  scarcely  transcends  the  limits  of  the 
wound  to  an  enormous  effusion  which,  as  it  increases, 
breaks  through  the  pia  mater  into  the  arachnoid  cavity 
and  may  suffice  to  spread  over  the  entire  vertex  and  to  fill 
all  the  basic  fossae.  If  the  hemorrhage  from  a  subcortical 
laceration  does  not  reach  the  cerebral  surface,  it  differs 
from  an  apoplectic  effusion  only  in  cause  and  attendant 
conditions. 


PATHOLOGY.  47 

These  several  hemorrhages  are  all  of  such  common 
occurrence  that  their  comparative  frequency  is  unimpor- 
tant. In  one  hundred  and  ninety-three  necropsic  cases 
appended,  exclusive  of  pistol-shot  wounds,  there  was  epi- 
dural hemorrhage  in  fifty-four,  pial  hemorrhage  in  sixty- 
nine,  and  cortical  hemorrhage  in  fifty-eight.  Two  or 
more  varieties  are  often  coincident,  of  which  one  is  likely 
to  outrank  the  others  either  in  extent  or  in  the  possible 
gravity  of  its  results.  The  epidural  blood  never  penetrates 
the  dura,  and  never  reaches  the  subarachnoid  spaces  except 
that  membrane  has  been  ruptured  by  the  violence  of  the 
original  injury.  The  pial  and  cortical  effusions  may  con- 
cur, and  may  be  localized  in  different  regions,  or  may  be 
commingled,  and  in  either  case  may  be  discriminated  by 
tracing  each  to  its  source,  unless  a  profuse  cortical  hemor- 
rhage has  overflowed  the  site  of  a  smaller  pial  extravasa- 
tion. If  no  cerebral  laceration  can  be  discovered,  it  is 
impossible  that  a  hemorrhage  should  be  of  cortical  origin. 

In  a  large  proportion  of  cases  hemorrhage  is  a  distinct 
factor  in  the  production  of  symptoms,  and  often  the  sole 
cause  of  a  fatal  termination.  It  is  questionable  if  it  is 
ever  an  absolutely  isolated  lesion.  It  is  oftener  secondary 
to  brain  laceration,  but,  when  primary,  some  degree  of 
general  or  local  contusion  or  an  independent  laceration 
may  still  coexist.  The  same  violence  which  is  sufficient 
to  separate  the  dura  mater  from  the  bone,  or  to  rupture 
the  vessels  of  the  pia  mater,  can  hardly  fail  further  to  be 
transmitted  to  the  brain  and  its  effect  ultimately  concen- 
trated in  a  limited  lesion  at  a  distant  point,  or  diffused  in 
a  general  contusion  of  its  substance.  A  hemorrhage  is 
often  regarded  as  uncomplicated,  from  want  of  sufficiently 
careful  necropsic  examination  of  the  brain  throughout  its 


48  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

whole  extent.  There  may  be  no  laceration  or  other  obvi- 
ous local  lesion,  and  general  contusion  is  readily  over- 
looked or  unappreciated.  This  almost  universal  fact  of 
complication  renders  the  direct  effects  of  hemorrhage  diffi- 
cult of  segregation,  and  has  probably  led  to  the  misappre- 
hension of  certain  symptoms  which  often  follow  in  its 
train. 

The  dangers  which  attend  intracranial  hemorrhage  are 
due  to  shock,  exsanguination  of  the  patient,  and  diminu- 
tion of  the  cranial  capacity.  If  the  effusion  reaches  the 
medulla  oblongata,  as  occasionally  happens,  life  is  termi- 
nated by  direct  compression  of  the  respiratory  ganglion ; 
otherwise  the  effect  of  encroachment  upon  the  intracranial 
space  is  diffused.  That  the  loss  of  blood  may  be  directly 
fat,al  is  sometimes  made  obvious  when  the  hemorrhage 
complicates  fracture.  In  cases  in  which  a  dural  sinus  has 
been  wounded,  death  has  sometimes  so  promptly  followed 
the  removal  of  an  osseous  fragment  as  to  make  its  immedi- 
ate cause  unmistakable ;  in  other  cases  in  which  compound 
fractures  have  involved  a  wound  of  a  larger  meningeal 
artery,  fatal  collapse  has  so  plainly  depended  upon  cardiac 
failure  as  to  leave  no  room  for  doubt.  In  the  larger  class 
of  cases  in  which  the  blood  extravasated  has  been  retained 
within  the  cranial  cavity,  the  hemorrhage  though  insuffi- 
cient, even  when  so  profuse  as  is  anatomically  possible  in 
that  situation,  to  cause  exsanguination,  may  still  render 
fatal  a  shock  from  which  recovery  had  been  otherwise  not 
hopeless,  or  may  by  producing  consecutive  asthenia  be 
distinctly  contributive  to  the  unfavorable  issue  of  associ- 
ated lesions. 

The  greater  number  of  deaths  in  which  hemorrhages 
seem  to  have  been  the  direct  cause  are  differently  occa- 


PATHOLOGY. 


49 


sioned  and  less  simply  interpreted.  They  have  been  gen- 
erally attributed  to  a  mechanical  compression  which  the 
brain  suffers,  the  result  of  the  intrusion  of  additional  mat- 
ter into  a  cavity  with  unyielding  walls  which  the  viscus 
exactly  fills ;  the  consequent  disturbance  of  circulation  and 
nutrition,  by  more  or  less  complete  obliteration  of  the  cere- 
bral capillaries,  has  been  as  generally  held  to  be  entirely 
adequate  to  the  explanation  of  all  the  characteristic  attend- 
ant symptoms.  In  this  view  the  effects  of  hemorrhage, 
purulent  effusion,  and  bone  depressed  have  been  regarded 
as  identical.  It  has  been  experimentally  demonstrated 
that  when  wax,  a  substance  incapable  of  absorption,  is  in- 
jected into  the  cranial  cavity  in  excess  of  a  maximum 
amount  of  6.5  per  cent.,  distinctive  symptoms  are  pro- 
duced, and  that  when  the  amount  reaches  one-twelfth  or 
one-sixth  of  the  cranial  capacity,  as  its  situation  is  epidural 
or  subdural,  fatal  coma  results.  As  the  effect  is  purely 
mechanical,  and  without  the  possibility  of  direct  brain  le- 
sion, there  can  be  no  doubt  of  its  dependence  upon  pressure 
or  compression.  The  term  compression  when  applied  to  a 
solid  organ  is  permissible,  since  the  reduction  of  its  bulk 
by  extrusion  of  its  fluids  is  no  less  real  than  when  accom- 
plished by  a  change  in  the  density  of  its  solid  constituents. 
That  the  resultant  vascular  disturbance  leads  to  deficient 
nutrition  must  be  conceded.  It  is  equally  beyond  ques- 
tion that  it  is  preceded  by  displacement  of  the  cerebro- 
spinal fluid  into  the  vertebral  canal,  which  continues  until 
the  capacity  of  that  diverticulum  is  exhausted,  and  that 
then  circulatory  interference  begins.  As  the  tension  of 
the  cerebro-spinal  fluid  is  augmented  under  pressure  of 
continued  extravasation  and  by  increasing  resistance  in 
the   vertebral   canal,  capillary   flow  is  checked  and  may 


50  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

cease  altogether,  with  complete  cerebral  anaemia  and  aboli- 
tion of  all  functional  control.  The  intercurrence  of  oedema 
from  capillary  transudation  may  further  increase  intracra- 
nial pressure.  If  the  hemorrhage  is  epidural,  sudden,  and 
profuse,  the  anaemic  condition  will  be  rapidly  attained  and 
complete,  and  its  manifestation  will  be  immediate  but  not 
instantaneous,  and  with  permanent  inhibition  of  conscious- 
ness; if  the  same  extravasation  is  more  gradual,  cerebral 
anaemia  may  never  become  complete,  or  not  until  time  has 
been  afforded  for  relief;  if  it  be  of  moderate  amount  as 
well  as  gradually  effused,  it  may  be  capable  of  absorption 
without  the  necessity  of  interference.  The  pial  and  corti- 
cal hemorrhages  are  rarely  sufficiently  copious  to  produce 
marked  cerebral  anaemia,  but  they  are  associated  with 
other  lesions,  which  contribute  to  a  fatal  result.  In  all 
these  instances  of  hemorrhage,  the  serious  interference 
with  vascular  supply  and  the  occurrence  of  answerable 
inhibitory  symptoms  are  comprehensible. 

There  are  other  and  smaller  infringements  upon  the 
intracranial  space  which  have  been  rated  as  agents  of  com- 
pression, but  which  are  quite  incapable  of  exercising  that 
amount  of  general  pressure  which  would  cause  even  par- 
tial capillary  occlusion.  The  uncomplicated  depression  of 
a  fragment  of  bone,  however  large,  could  scarcely  diminish 
the  cranial  capacity  beyond  the  space  gained  by  practi- 
cable displacement  of  the  cerebro-spinal  fluid,  to  an  extent 
which  would  appreciably  disturb  the  general  cerebral  nu- 
trition. It  might  by  local  pressure  cause  temporary  im- 
pairment or  abrogation  of  a  function  controlled  by  a  centre 
directly  involved,  but  a  compression  of  the  entire  cere- 
brum would  be  inconceivable.  The  possibility  of  an  epi- 
dural or  other  abscess  being  permitted  to  attain  a  bulk 


PATHOLOGY.  5 i 

sufficient  to  cause  general  compression  should  be  scarcely 
more  conceivable  in  the  present  epoch  of  surgical  practice. 
The  general  symptoms  which  attend  these  inconsiderable 
curtailments  of  the  intracranial  space,  whatever  their  na- 
ture, must  therefore  be  ascribed  to  other  causes  than  a 
general  circulatory  disturbance  occasioned  by  the  contrac- 
tion of  cranial  capacity.  The  almost  invariable  concur- 
rence of  other  intracranial  lesions  with  hemorrhage  sug- 
gests their  source. 

Pressure  and  compression  are  mechanical  agencies,  and 
not  pathological  conditions ;  the  action  of  one  is  limited, 
and  of  the  other  diffuse.  Hemorrhage  causes  either  pres- 
sure or  compression,  as  blood  is  extravasated  in  small  or 
large  amount;  depression  of  bone  or  the  epidural  effusion 
of  pus  cause  pressure.  The  symptoms  of  the  compression 
caused  by  large  arachnoid  inflammatory  effusions  are 
merged  in  those  of  the  disease  in  which  they  mark  the 
final  stage. 

The  attempt  to  combine  the  symptomatic  and  pathic 
conditions  of  hemorrhages  of  different  grades,  depression 
of  bone,  and  inflammation,  like  other  unwarranted  gen- 
eralizations, has  led  to  confusion,  obscurity,  and  much 
misapprehension . 

In  cases  destined  to  recovery,  the  blood  extravasated 
ordinarily  disappears  by  absorption,  and  such  a  termina- 
tion is  frequent  when  the  amount  is  small.  It  is  also  ob- 
served after  hemorrhages  of  considerable  extent,  when 
some  portion  has  been  removed  by  the  aid  of  trephination. 
If  after  an  interval  of  months  the  patient  dies,  its  final 
traces  may  be  sometimes  noted  as  a  mere  yellow  stain 
above  or  below  the  dura.  Cystic  degeneration  is  of  occa- 
sional occurrence,  and  is  most  likely  to  be  a  transformation 


52  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

of  an  epidural  clot  complicating  depressed  fracture.  In 
this  way  it  comes  to  be  encountered  from  time  to  time  in 
trephining  for  traumatic  epilepsy.  The  purulent  infection 
of  a  clot  even  in  the  substance  of  the  brain  is  not  only 
possible  but  may  exceptionally  occur  without  negligence 
on  the  part  of  the  surgeon. 

2.  Thromboses  of  Dural  Sinuses. 

The  occurrence  of  thrombi  in  the  dural  and  basic  si- 
nuses, perhaps  extending  into  the  jugular  vein,  which  are 
neither  marasmic  nor  infective,  is  occasional  and  not 
always  susceptible  of  adequate  explanation.  This  con- 
dition may  affect  any  one  of  these  canals  and  is  concurrent 
with  other  and  varying  anatomical  lesions.  The  throm- 
bus may  be  wholly  or  partially  decolorized,  is  non-adher- 
ent, and  is  likely  to  extend  from  the  superior  longitudinal 
sinus  or  torcular  Herophili  through  the  lateral  and  petro- 
sal sinuses.  In  one  of  the  appended  cases  the  wall  of  the 
posterior  part  of  the  superior  vSinus  was  infiltrated  with 
blood  at  a  point  immediately  below  a  compound  fracture, 
with  laceration  of  the  meninges  and  extensive  epidural, 
pial,  and  cortical  hemorrhages.  As  the  thrombosis  began 
at  the  site  of  injury,  it  was  probably  the  result  of  the  direct 
lesion  of  the  sinus  wall.  In  another  case,  as  the  thrombus 
extended  from  the  jugular  vein  into  the  torcular  Hero- 
phili and  a  cranial  fissure  terminated  in  the  jugular  fora- 
men, there  is  again  probability  of  direct  injury.  In  a 
third  case  there  was  no  fracture  or  intracranial  injury 
other  than  a  general  contusion  and  thrombosis  of  the 
minute  cerebral  vessels,  most  pronounced  at  the  base  and 
upon  the  left  side.  The  thrombus,  which  was  decolorized, 
occupied  both  lateral  and  both  petrosal  sinuses.     These 


PATHOLOGY.  53 

cases,  in  which  the  thrombi  were  all  of  ante-mortem  for- 
mation, were  pathologically  independent  of  each  other,  and 
unconnected  with  pressure  or  with  any  inflammatory  proc- 
ess within  or  without  their  walls,  or  with  any  dyscrasia  of 
the  patient.  They  were  non-infective  and  had  no  appre- 
ciable influence  in  symptomatology.  It  is  conceivable 
that  by  closure  of  the  jugular  vein  they  should  occasion 
external  symptoms  of  venous  obstruction,  and  such  have 
been  observed  in  recovering  cases  in  which  it  was  sus- 
pected. Their  clinical  value  is  yet  to  be  discovered,  but 
their  occurrence  must  be  recognized  as  one  of  the  several 
intracranial  traumatic  lesions. 

3.  Contusion. 

Intracranial  contusion  may  be  cerebral  or  meningeal, 
and  in  either  structure  may  be  limited  or  diffuse. 

a.    General  Contusion  of  the  Brain. 

This  condition  probably  exists  in  some  degree  in  all 
cases  of  intracranial  injury,  and  may  affect  the  entire 
organ  or  be  confined  to  the  cerebrum.  It  is  infrequent  as 
an  absolutely  isolated  lesion,  of  rather  more  common 
occurrence  as  an  essential  change,  and  almost  constant  in 
connection  with  a  considerable  hemorrhage  or  laceration. 
It  has  often  escaped  observation,  partly  by  reason  of  its 
diffused  character  and  its  coexistence  with  more  obvious 
alterations  of  structure,  and  partly  from  the  still  general 
acceptance  of  a  theoretical  basis  of  functional  disturbance 
as  an  adequate  explanation  of  symptoms.  The  visible  an- 
atomical changes  are :  a  distention  of  the  parenchymatous 
vessels,  a  general  formation  of  minute  throm.bi,  the  pres- 
ence of  punctate  extravasations,  and  a  more  or  less  distinct 


54  INJURIES    OF   THE   BRAIN    AND    MEMBRANES. 

oedema.  The  punctate  extravasations  which  are  character- 
istic of  limited  contusion  are  rarely  seen  in  this  general 
form  of  the  same  lesion,  and  then  perhaps  only  singly  and 
at  widely  different  points.  If  the  hemorrhages  are  larger, 
even  of  the  size  of  a  buck  shot,  they  are  the  result  not  of 
contusion  but  of  laceration.  It  is  not  an  arbitrary  distinc- 
tion, and  the  line  is  drawn  at  punctate  extravasations,  not 
only  because  it  is  definite  but  because  it  is  the  probable 
limit  at  which  the  effusion  ceases  to  be  purely  interstitial 
and  becomes  destructive  of  tissue.  The  minute  thrombi 
are  the  most  characteristic  of  the  several  morbid  conditions 
which  have  been  enumerated,  since  they  are  almost  if  not 
quite  unknown  after  death  from  idiopathic  disorders  in 
which  hyperaemia  has  been  excessive.  The  oedema,  which 
is  variable  in  amount,  sometimes  appreciable  only  after 
some  delay  and  a  close  inspection  upon  section,  and  at 
other  times  so  profuse  that  the  fluid  can  be  squeezed  from 
the  brain  by  the  hand  as  from  a  sponge,  is  notably  frequent. 
All  these  abnormal  conditions,  the  extravasations,  thrombi, 
and  oedema,  are  simply  measures  of  the  general  hyperae- 
mia which  immediately  preceded  death.  The  primary  or 
intervening  transient  changes  which  induced  the  final  vas- 
cular fluxion  can  be  inferred  only  from  symptoms  and  an- 
alogy. It  is  demonstrated  by  Boise  that  general  shock  is 
a  hyperirritation  of  the  entire  sympathetic  nervous  system, 
occasioned  by  some  sudden  and  more  or  less  violent  im- 
pression, and  causing  contraction  of  the  arterioles  by  stim- 
ulation of  the  vasomotor  nerves.  The  character  of  its 
symptoms  indicates  the  deficient  vascular  supply.  The 
immediate  inhibitory  symptoms  which  attend  a  violent 
injury  of  the  head  would  seem  to  depend  upon  a  similar 
irritation  of  the  cerebral  centres  of  vascular  control  with 


PATHOLOGY.  55 

contraction  of  the  cerebral  vessels;  to  this  succeed  by- 
continued  irritation  paralysis  and  dilatation.  The  brain 
is  primarily  made  anaemic ;  with  the  secondary  dilatation 
of  its  vessels,  as  hypersemia  becomes  excessive,  it  is  again 
anaemic  in  effect  from  more  or  less  complete  cessation  of 
capillary  movement  and  from  oedema.  The  result  of  com- 
pression and  of  general  brain  contusion  is  the  same,  and  it 
is  the  frequent  coexistence  of  contusion  with  the  pressure 
of  depressed  bone  which  has  led  to  the  confusion  of  pres- 
sion  with  compression.  If  the  cortical  centres  recover 
from  the  shock,  the  circulation  is  readjusted. 

In  accepting  vascular  derangements  as  the  source  of 
symptoms  in  intracranial  contusion,  it  has  been  sought  by 
some  previous  writers  to  interpose  certain  physical  proc- 
esses between  the  application  of  external  violence  and 
the  impression  made  upon  the  nerve  centres.  Miles,  in  an 
elaborate  study  of  this  subject,  and  as  a  result  of  experi- 
mental and  speculative  considerations,  accepts  Buret's 
theory  of  the  formation  of  consecutive  areas  of  cranial 
depression  and  bulging,  causing  temporary  compression 
and  forcing  the  fluid  of  the  lateral  ventricles  into  the 
fourth  ventricle  and  the  spinal  subarachnoid  space:  and 
from  overdistention  of  the  fourth  ventricle  involving  rup- 
ture of  its  floor  and  lesions  of  contiguous  parts,  including 
the  medulla.  A  stimulation  of  the  restiform  bodies  is 
assumed  to  follow,  and  a  consequent  efferent  reflex  action 
which  directly  occasions  the  capillary  contraction.  It  may 
be  objected  to  this  explanation  that  it  is  unnecessarily 
complex,  since,  from  the  analogy  of  general  shock,  the 
direct  transmission  of  the  nervous  impression  from  the 
external  surface  is  equally  conceivable ;  and  still  further 
that  post-mortem  examination  of  cases  in  which  even  ex- 


56  INJURIES    OF    THE   BRAIN   AND    MEMBRANES. 

treme  contusion  is  found  to  exist  does  not  disclose  such 
localized  lesions  in  the  neighborhood  of  the  fourth  ven- 
tricle as  were  said  to  result  from  experimentation.  The 
immediate  tetanic  effects  observed  in  the  experiments 
upon  animals,  made  both  by  Miles  and  by  Duret,  are  also 
absent  in  contusion  of  the  human  brain,  unaccompanied 
by  laceration  or  hemorrhage. 

The  invention  and  application  of  a  fanciful  term  to 
comprehend  all  combinations  of  symptoms  and  pathic  con- 
ditions, when  the  brain  is  not  supposed  to  be  compressed, 
has  met  with  great  acceptance.  All  traumatisms  involv- 
ing brain  symptoms,  were  for  many  years  classified  as 
cases  of  concussion  or  of  compression.  The  classification 
was  simple  and  of  easy  comprehension.  If  the  intracra- 
nial space  was  diminished  by  the  intrusion  of  bone,  serum, 
extravasated  blood,  or  pus,  it  was  compression;  otherwise 
all  symptoms  were  referred  to  a  hypothetical  vibration  of 
the  brain  within  the  skull,  a  merely  functional  disorder 
produced  by  violence.  Thirty  years  ago  Prescott  Hewitt 
described  several  forms  of  contusion,  in  which  he  included 
lacerations,  and  questioned  the  occurrence  of  concussion 
as  a  distinctive  pathic  condition  independent  of  anatomical 
change.  Previous  to  this  time  several  observers  had  noted 
structural  alterations  in  certain  suddenly  fatal  cases  which 
had  presented  the  symptoms  attributed  to  concussion,  but 
had  not  recognized  the  existence  of  perceptible  lesion 
when  life  was  further  prolonged  or  recovery  ensued.  Mr. 
Hewitt,  in  suggesting  that  all  cases  of  concussion  are  at- 
tended by  some  appreciable  lesion,  made  a  distinct  advance 
in  the  study  of  the  pathology  of  cerebral  trauma.  He  did 
not,  however,  distinguish  contusion  from  laceration  or 
hemorrhage  in  the  classification  of  cases.     Though  a  belief 


PATHOLOGY.  57 

in  a  physical  basis  for  all  cerebral  symptoms  occasioned  by 
injuries  of  the  head  became  more  widely  extended,  von 
BeroTnann  some  vears  later  in  a  clinical  lecture  admitted 
the  existence  of  both  concussion  and  compression,  with  an 
etiological  difference,  and  insisted  upon  their  clinical  iden- 
tity. He  attributed  concussion  to  a  direct  injury  from  a 
single  impulse,  modified  by  the  elasticity  of  the  skull,  by 
which  the  brain  suffered  a  diffuse  disturbance  without  ap- 
preciable lesion.  He  considered  it  a  suspension  of  cortical 
activity,  followed  by  a  stimulation  and  eventually  by  a 
depression  of  the  medulla.  He  regarded  it  as  occurring 
in  three  degrees :  as  involving  paralysis  of  the  cortex  only, 
as  a  paralysis  of  the  cortex  and  a  stimulation  of  the  me- 
dulla, and  as  a  paralysis  of  both  cortex  and  medulla  with 
a  primary  brief  and  unobserved  medullary  stimulation. 
Cortical  paralysis  was  indicated  by  unconsciousness ;  med- 
ullary stimulation  by  slowness  of  pulse  and  increase  of 
arterial  tension ;  and  medullary  paralysis  by  rapidity  of 
pulse  and  decreased  arterial  tension.  In  compression,  he 
regarded  the  brain  condition  as  identically  the  same  and 
as  manifested  by  the  same  symptoms,  but  as  due  to  change 
of  cranial  capacity  and  not,  as  in  concussion,  to  change  of 
cranial  form.  Finally,  he  considered  diagnosis  as  only 
possible  by  the  duration  of  the  symptoms.  The  views  of 
von  Ber^mann  are  of  too  sfreat  weight  and  authoritv  to  be 
lightly  questioned;  but  since  the  time  at  which  he  wrote, 
further  observation  has  shown  that  the  diffuse  disturbance 
he  terms  concussion  is  connected  with  evident  lesion ; 
and,  while  the  vascular  derangements  caused  by  compres- 
sion of  the  brain  substance  may  be  identical  with  those 
due  to  direct  injury,  recognition  must  certainly  be  given 
to  the  presence  of  the  compressing  agent  within  the  era- 


58  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

nial  cavity  by  which  clinical  as  well  as  etiological  differ- 
ences are  established.  Concussion  and  compression,  hav- 
ing been  consolidated  by  von  Bergmann,  should  be 
abolished  together,  so  far  as  they  are  terms  used  to  ex- 
press a  pathic  condition. 

The  impossibility  of  accepting  a  functional  disorder  as 
adequate  explanation  of  the  group  of  symptoms  which 
has  been  collectively  known  as  concussion,  resides  in  the 
fact  that  in  recovering  cases  it  is  purely  an  assumption 
which  is  contradicted  by  the  necropsic  appearances  ob- 
served in  those  which  are  fatal.  Structural  alterations 
have  been  denied,  not  only  without  reason  but  in  despite 
of  positive  evidence.  In  every  fatal  case,  when  the  clini- 
cal history  has  corresponded  to  that  of  those  which  have 
recovered,  a  carefully  conducted  necropsy  has  revealed 
organic  lesion.  In  all  the  instances  which  have  been  cited 
to  prove  the  absence  of  lesion,  not  one  has  been  noted 
with  sufficient  exactitude  to  give  it  the  slightest  statistical 
value.  There  is  nothing  in  analogy  to  warrant  at  the 
present  time  the  assumption  that  any  fatal  disorder  termi- 
nates without  involving  structural  change.  Even  dis- 
orders of  the  nervous  system,  long  considered  functional, 
have  with  closer  investigation  fallen  more  and  more  into 
line  with  organic  diseases.  It  may  properly  be  held,  both 
from  post-mortem  observation  and  from  analogy,  that  brain 
injury  produces  structural  alteration  wdth  the  same  cer- 
tainty that  it  occasions  palpable  symptoms.  If  the  W'ords 
concussion  and  compression  be  used  to  indicate  a  group  of 
symptoms  or  variations  of  pathic  condition,  it  is  objection- 
able, both  on  the  score  of  propriety  and  of  exactitude  and 
as  being  likely  to  lead  to  erroneous  diagnosis.  If  they  be 
discarded,  the  form  of  injury  the  patient  has  suffered,  as 


PATHOLOGY.  59 

laceration,  general  contusion,  or  fracture  with  hemorrhage, 
is  more  likely  to  be  accurately  determined  than  if  attention 
be  directed  solely  to  a  symptomatic  condition  that  may  not 
clearly  exist. 

If  the  cortical  centres  recover  from  the  shock  to  which 
they  have  been  subjected,  the  circulation  is  readjusted,  the 
punctate  extravasations  and  serous  transudations  are  re- 
absorbed, and  it  is  probable  no  physical  vestige  of  struc- 
tural alteration  remains.  There  is  a  subsequent  instability 
of  cerebral  nutrition,  which  has  been  recognized  as  a 
sequel  of  intracranial  injury,  and,  as  it  also  occurs  after  all 
lesions  in  which  contusion  is  a  complication,  it  is  probably 
due  to  an  increased  susceptibility  of  the  vasomotor  centres, 
and  a  consequent  liability  from  trivial  cause  to  the  occur- 
rence of  transient  conditions  of  either  anaemia  or  hyper- 
aemia.  Such  persons  are  often  unable  to  endure  serious 
mental  or  physical  labor,  exposure  to  the  sun,  moderate 
alcoholic  stimulation,  or  many  other  of  the  fatigues  and 
pleasures  incident  to  ordinary  life.  This  fact  was  officially 
recognized  in  the  later  part  of  the  war  of  secession,  and 
men  who  had  recovered  from  a  head  injury  of  any  kind 
were  relegated  to  the  invalid  corps. 

b.  Limited  Contusion  of  the  Brain. 

This  lesion  may  be  confined  to  the  cortex,  or  may  exist 
subcortically  in  any  region  of  the  organ.  It  may  be  said 
to  differ  from  laceration,  as  a  contusion  elsewhere  differs 
from  a  wound.  It  is  a  bruising  of  the  tissue  with  minute 
hemorrhages  and  possible  molecular  disintegration,  and 
in  both  particulars  is  distinguishable  from  general  con- 
tusion. The  hemorrhages  are  characteristically  in  punc- 
tate form  and  are  thickly  scattered  among  the  cells  and 


6o  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

capillary  vessels.  As  it  occurs  upon  the  surface  in  a  single 
area,  or  perhaps  in  two  or  more  different  regions,  it  may 
occcupy  a  space  from  a  fraction  of  an  inch  to  one  or  two 
inches  in  diameter,  and  is  a  simple  bruise.  It  is  slightly 
depressed  and  variously  discolored  from  dark  red  to  yel- 
lowish-gray, and  without  arachnoid  laceration.  In  the 
subcortical  substance  it  appears  in  similar  areas  as  an 
aggregate  of  punctate  extravasations  with  or  without  a 
yellowish  or  darker  stain  of  the  intervening  tissue.  In 
general  contusion  it  may  happen  that  the  change  is  lim- 
ited to  a  single  hemisphere  or  to  a  single  lobe,  but  is  still 
comparatively  large,  and,  as  its  anatomical  peculiarities  are 
different,  it  is  to  be  regarded  rather  as  a  regional  form  of 
the  general  lesion  than  as  a  limited  contusion. 

This  is  the  most  infrequent  form  of  intracranial  injury, 
and  without  complication  is  almost  exceptional.  It  indi- 
cates the  direct  transmission  of  a  certain  degree  of  force, 
in  place  of  its  entire  diffusion ;  that  it  stops  short  of  lac- 
eration is  because  force  is  possibly  minimized,  in  some 
instances  and  in  some  measure,  from  the  amount  of  resist- 
ance which  it  encounters. 

If  the  lesion  is  superficial,  whether  it  be  a  laceration  or 
a  mere  contusion,  it  is  oftener  than  elsewhere  at  the  base 
of  the  brain,  and  in  the  anterior  or  middle  fossa.  In  itself 
it  is  unimportant  except  as  it  is  contributory  to  the  effects 
of  the  general  injury,  and  has  no  distinctive  indications. 
Its  relation  to  subsequent  infective  changes  will  demand 
later  consideration. 


PATHOLOGY.  6l 

c.    Contusion  of  the  Meninges. 

Meningeal  contusion  has  not  been  heretofore  appreci- 
ated or  described  as  one  of  the  distinctive  lesions  in  intra- 
cranial injury.  It  may  be  more  or  less  prominent  than 
the  cerebral  contusion  which  it  accompanies,  and  while  it 
may  be  the  paramount  apparent  lesion  it  is  probably  no 
more  entirely  independent  of  general  cerebral  contusion 
than  is  a  laceration  or  a  hemorrhage.  It  is  incredible  that 
force  should  be  so  strictly  localized  as  utterly  to  expend 
itself  in  a  structure  so  thin  and  delicate  as  the  pia  mater, 
to  which  meningeal  contusion  is  apparently  restricted. 
Its  relation  in  extent  and  severity  to  general  cerebral  con- 
tusion is  not  clearly  defined,  but  they  are  not  always 
directly  proportionate,  and  either  one  may  be  relatively 
excessive.  It  may  be  largely  or  universally  diffused,  or 
may  be  limited  to  areas  not  larger  than  the  localized  in- 
juries of  the  cortex.  It  is  legitimate  inference  that  the 
evident  vascular  derangements  are  produced,  as  they  are 
in  the  brain  substance,  by  the  shock  impressed  upon  the 
vasomotor  centres.  The  same  conditions,  hyperasmia, 
oedema,  and  hemorrhages,  are  apparent.  The  punctate 
extravasations  are  more  numerous  and  more  frequently 
observed,  and  moderately  profuse  hemorrhages,  which  are 
unknown  in  the  diffused  cerebral  lesion,  are  of  common 
occurrence  in  patches,  in  thin  sheets  spread  over  the  ver- 
tex, or  in  quantity  sufficient  to  break  into  and  fill  the 
arachnoid  cavity.  The  difference  in  the  amount  of  ex- 
travasation which  follows  engorgement  of  the  vessels 
depends  upon  the  anatomical  peculiarities  of  the  pial 
membrane.  The  vessels  are  comparatively  large,  with 
feeble  support  from  the  loose  areolar  tissue  which  they 


62  INJURIES   OF    THE    BRAIN   AND    MEMBRANES. 

traverse,  while  in  the  brain  substance  the  circulation  is 
maintained  through  capillaries  and  arteries  of  the  smallest 
size,  which  are  greatly  strengthened  by  the  denser  struc- 
ture in  which  they  lie.  Even  in  the  largest  pial  hemor- 
rhages it  is  unnecessary  to  suppose  that  there  has  been 
rupture  of  the  membrane  from  direct  transmission  of  force. 
The  vessels  give  way  from  the  lateral  pressure  of  over- 
distention,  and,  if  the  areolae  are  torn,  it  results  second- 
arily, from  the  profuseness  of  the  hemorrhagic  effusion. 
Limited  hemorrhages  which  have  infiltrated  the  pia  may 
be  demonstrably  without  laceration  of  its  areolar  struc- 
ture. 

Hemorrhage  is  the  usual  indication  of  this  meningeal 
form  of  contusion,  and  was  observed  in  sixty-eight  of  the 
appended  series  of  necropsies.  Its  greatest  relative  fre- 
quency was  in  intracranial  injuries  without  fracture,  and 
its  least  was  in  connection  with  fractures  of  the  vertex. 
This  estimate  is  independent  of  simple  hypersemias  and 
punctate  extravasations.  The  termination  of  these  cases 
is  not  unlike  that  of  other  intracranial  hemorrhages  in  the 
circumstances  of  recovery  or  death. 

In  place  of  a  hemorrhage,  a  subarachnoid  serous  effu- 
sion is  sometimes  encountered,  as  a  result  of  the  hyperaemia 
which  follows  meningeal  contusion.  It  is  not  of  frequent 
occurrence  and  is  readily  mistaken  for  an  inflammatory 
process.  It  may  be  recognized  as  a  perfectly  clear  fluid, 
confined  to  limited  areas,  and  unaccompanied  by  arach- 
noid opacity.  It  may  cover  a  single  lobe,  or  a  space  not 
more  than  one  or  two  inches  in  diameter,  and  like  other 
evidences  of  contusion  these  transudations  m.ay  be  single 
or  multiple.  Several  instances  in  which  the  cedematous 
may  be  discriminated  from  the  inflammatory  effusion  are 


PATHOLOGY.  63 

to  be  found  in  the  appended  series  of  necropsic  observa- 
tions. It  is  not  to  be  expected  that  it  can  be  detected  dur- 
ing life,  since  even  when  considerable  in  amount  it  is  still 
insufficient  to  occasion  symptoms  of  compression. 

There  is  a  sequel  of  meningeal  contusion  in  an  inflam- 
matory process  similar  to  that  of  the  limited  visceral  lesion, 
which  will  be  included  in  the  study  of  secondary  traumatic 
inflammations. 

4.  Laceration   of   the   Brain. 

Laceration  of  the  brain  is  the  final  expression  of  limited 
force  in  its  greatest  intensity.  It  may  be  cortical  or  sub- 
cortical, single  or  multiple,  trivial  or  important.  If  less 
absolutely  constant  than  general  contusion,  it  is  even  more 
frequently  encountered  as  an  emphasized  lesion.  In  the 
whole  number  of  necropsies  upon  which  these  propositions 
are  based,  it  occurred  in  one  hundred  and  twenty-eight, 
and  in  ninety-four  was  evidently  the  source  of  symptoms 
or  the  cause  of  death.  It  is  not  always  possible  to  deter- 
mine the  extent  of  the  original  wound,  since  so  many  and 
so  considerable  vessels  are  likely  to  be  ruptured,  and  the 
consequent  hemorrhage  to  be  so  profuse  that  the  brain 
substance  mav  be  broken  down  to  a  great  distance  and  in 
every  direction.  It  is  not  unusual  for  an  entire  lobe  to 
be  excavated  and  disintegrated,  or  even  the  greater  part 
of  a  hemisphere  to  be  similarly  destroyed.  These  enor- 
mous subcortical  lacerations  may  break  through  the  cortex, 
and  the  extravasated  blood  spread  over  the  whole  surface 
of  the  brain ;  or  they  may  remain  strictly  confined  to  the 
parenchyma  in  which  they  originated,  enclosed  only  in  a 
mere  shell  of  the  cortical  substance.  In  other  cases  they 
are  scarcely  larger  or  more  important  than  the  most  incon- 


64  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

siderable  limited  contusion,  from  which  they  are  dis- 
tinguishable only  by  the  relatively  greater  amount  of 
hemorrhage  which  they  involve.  Between  these  extremes 
they  present  every  gradation  of  destructive  injury.  Like 
fractures  and  limited  contusions,  they  are  oftenest  discov- 
ered in  the  basic  region,  and  in  the  majority  of  instances 
affect  the  frontal  and  temporal  lobes.  There  is  no  por- 
tion of  the  brain,  however,  which  may  not  be  wounded; 
neither  the  interior  of  the  cerebellum,  pons,  medulla,  optic 
thalamus,  or  corpus  striatum,  nor  the  fornix  or  gj-rus  forni- 
catus;  no  ganglion  or  convolution  is  exempt  from  this 
result  of  violence.  In  the  cases  examined,  exclusive  of 
the  fractures  of  the  vertex  in  which  lesion  was  produced 
by  the  direct  application  of  force,  some  part  had  been 
lacerated  in  nearly  seventy-five  per  cent.,  and  in  by  far 
the  larger  proportion  it  was  the  inferior  surface  of  the 
frontal  or  temporal  lobes.  Lacerations  again,  like  limited 
contusions  and  indirect  fractures,  almost  invariably  occur 
at  points  directly  opposite  that  at  which  force  has  been 
applied.  It  has  been  supposed  that  this  fact,  as  it  affects 
visceral  lesions,  is  to  be  explained  by  a  sudden  displace- 
ment of  the  brain,  which  in  its  rebound  strikes  against  the 
cranial  wall  and  is  bruised  or  wounded  by  its  sharp  or  rug- 
ged prominences,  and  that  this  specially  accounts  for  the 
greater  liability  to  injury  to  the  inferior  surface  of  the 
lobes  which  occupy  the  anterior  and  middle  fossae.  This 
theory  is  unsatisfactory,  not  only  because  there  is  no  evi- 
dence that  such  movements  take  place  within  the  cranial 
cavity,  but  because  the  local  superficial  lesions  by  no  means 
usually  correspond  to  the  situation  of  the  bony  processes 
and  irregularities,  and  because  it  fails  to  account  for  the  cen- 
tral lesions.     Their  production  has  been  also  ascribed  to 


PATHOLOGY.  65 

the  change  of  form  suffered  by  the  skull  in  virtue  of  its 
elasticity  when  subjected  to  violence,  which  causes  distor- 
tion of  the  brain  to  the  point  of  rupture.  It  would  seem, 
if  this  interpretation  were  correct,  that  the  brain  tissue 
should  give  way  at  one  or  the  other  extremity  of  the 
lengthened  axis,  and  not  so  generally  in  the  shortest  diam- 
eter. Another  explanation,  which  is  suggested  by  Miles, 
is  that  in  the  displacement  of  the  cerebro-spinal  fluid  by 
the  consecutive  cranial  depression  and  bulging,  which  he 
believes  to  follow  a  blow  upon  the  head,  a  momentary 
vacuum  is  formed  at  either  end  of  the  axis  of  force,  and 
the  vessels  of  the  brain  and  membranes  rupture  from  lack 
of  support.  Granting  the  correctness  of  the  premises, 
superficial  vascular  lesions  might  occur  in  this  manner, 
but  hardly  the  considerable  laceration  of  tissue,  which  is 
often  in  excess  of  the  injury  to  vessels.  It  is  still  more 
difficult  to  conceive  of  lacerations  in  the  central  portions 
of  the  brain  as  being  produced  by  these  transient  and  dis- 
tant if  not  trivial  fluctuations  of  the  cerebro-spinal  fluid, 
while  the  immediate  and  firmer  support  of  the  general 
parenchyma  remains  intact,  and  the  delicate  walls  of  the 
pial  vessels  perhaps  remain  uninjured.  There  remains 
only  the  possibility  of  a  direct  propagation  of  force  from 
its  point  of  application,  in  straight  lines  through  the  inter- 
vening parts  to  the  site  of  local  injury,  with  such  diffusion 
through  the  yielding  cerebral  substance  as  is  manifest  in 
the  general  lesions.  There  is  no  greater  difficulty  in  ac- 
cepting this  simple  explanation  than  in  admitting  the  sim- 
ilar transmission  of  force  through  other  media. 

The  cortical  lacerations  are,  when  recent,  merely  lace- 
rated wounds  containing  more  or  less  blood  coagulum,  with 
underlying  shreds  and  granular  detritus  of  brain  tissue ; 

5 


66  INJURIES    OF   THE    BRAIN   AND    MEMBRANES, 

their  base  is  usually  pultaceous  and  stained  with  blood  or 
of  a  grayish  color.  The  contiguous  brain  matter  may  be 
softened  or  dotted  with  miliary  extravasations,  but  is 
oftener  of  normal  consistence  and  appearance.  The  wound 
may  be  circular,  oval,  or  irregular  in  outline,  not  larger 
than  a  pea  or  perhaps  covering  the  whole  extent  of  the 
inferior  surface  of  the  frontal  or  temporal  lobe.  The  re- 
sulting hemorrhage  constitutes  the  cortical  extravasation 
already  described.  The  .subcortical  lacerations  are  usually 
more  or  less  irregular  cavities  filled  with  blood,  but  after 
the  removal  of  the  clot  their  walls  present  the  same  ragged, 
discolored  appearance,  and  the  adjacent  tissue  the  possible 
miliary  extravasations  which  characterize  the  superficial 
lesions. 

The  subsequent  history  of  these  wounds  is  usually  sim- 
ple. If  they  are  of  considerable  size,  death  ensues  in  a  ma- 
jority of  cases  before  sufficient  time  has  elapsed  to  permit 
any  change  of  importance.  The  end  to  be  hoped  for  in  any 
wound  with  loss  of  tissue  is  cicatrization.  Recoveries  are 
by  no  means  exceptional  in  which  laceration  seems  to  have 
been  verified  by  symptoms,  yet  evidences  of  such  a  repara- 
tive process  have  rarely  been  discovered  in  the  course  of 
necropsic  examinations.  It  is  probable  that  small  cica- 
trices are  difficult  of  detection,  and  that  large  lacerations 
are  not  prone  to  heal.  There  is  warrant,  however,  for  the 
statement  that  fibrous  cicatricial  tissue  may  be  formed, 
and  the  late  Dr.  Alonzo  Clark  described  in  detail  the  re- 
generation of  nerve  fibres  after  the  occurrence  of  intra- 
cerebral hemorrhage.  The  formation  of  cysts,  areolar 
tissue,  and  adventitious  membranes,  and  various  degen- 
erative changes  have  been  noted  as  terminations  or  results. 
Mr.  Hewitt  refers  to  a  case  in  which  two  large  cerebral 


PATHOLOGY.  6/ 

lacerations,  uncomplicated  by  cranial  fracture,  were  exam- 
ined after  many  years.  The  surface  was  excavated  and 
the  arachnoid  membrane  bridged  a  cavity  filled  with  serum 
and  loose  areolar  tissue.  In  a  case  of  gunshot  wound,  in- 
cluded in  the  appended  series,  the  brain  track  after  thir- 
teen years  was  converted  into  a  membranous  canal.  The 
process  of  reparation  is  evidently  slow.  After  the  lapse 
of  seven  months  lacerations  have  been  found  to  be  still 
distinctly  limited,  uncontracted,  softened,  rusty  in  color, 
and  without  apparent  inflammatory  alteration. 

The  fatalities  which  immediately  follow  intracranial 
injury  with  laceration,  are  probably  to  be  ascribed  to  con- 
comitant hemorrhage  or  general  contusion ;  those  in  which 
the  laceration  is  the  essential  cause  of  death  occur  during 
a  period  which  may  be  estimated  as  extending  from  the 
end  of  the  first  forty-eight  hours  to  six  weeks.  During 
the  first  few  days  the  contained  clot  becomes  darker  and 
more  friable;  at  a  later  period,  when  death  seems  to  have 
been  due  to  laceration  the  wound  has  often  assumed  a 
sloughy  appearance,  which,  with  the  antecedent  symptoms, 
points  to  a  septic  infection.  No  inflammatory  changes 
have  been  discovered  in  repeated  microscopical  examina- 
tions. 

These  several  organic  lesions  represent  the  whole  ex- 
penditure of  the  force  derived  from  external  violence, 
upon  the  cranium  and  its  contents:  fractures  limited  to 
the  point  of  impact  or  propagated  to  a  distance,  limited  or 
diffused  contusions  of  the  pia  mater,  wounds  and  bruises 
of  the  brain  substance,  and  resulting  hemorrhages  from 
the  osteo-meningeal  and  cerebral  vessels,  with  occasional 
thromboses  of  the  dural  sinuses.  These  traumatic  con- 
ditions are  variously   complicated  with   each   other;    and 


68  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

general  cerebral  contusion,  which  is  probably  a  constant 
factor  in  all  intracranial  injuries,  may  also  occur  as  an  iso- 
lated lesion. 

Secondary  Inflammations. 

The  traumatic  intracranial  inflammations  are  secondary 
to  the  immediate  structural  changes  which  have  been  de- 
scribed. They  are  properly  sequelae  rather  than  compli- 
cations, not  only  because  they  are  chronologically  later, 
but  because  the  primary  lesion  comes  between  them  and 
the  receipt  of  injury.  Their  development  may  not  be 
identically  the  same  in  all  cases,  but  ordinarily  if  not  in- 
variably there  are  involved  a  structural  alteration,  the  direct 
result  of  traumatism,  which  is  essential,  and  a  later  infec- 
tion, which  is  accidental.  These  two  factors  in  their  pa- 
thogeny may  be  considered  fundamental.  It  is  always  haz- 
ardous to  proclaim  generalizations  to  be  without  exception, 
but  the  universality  of  the  law  that  some  appreciable  in- 
jury of  cerebral  or  meningeal  tissue  precedes  its  traumatic 
inflammation  is  sustained  so  far  as  observation  is  prac- 
ticable. There  are  meningites  in  which  the  pia  mater  is 
so  greatly  altered  by  the  secondary  processes,  and  chronic 
abscesses  of  the  brain  in  which  the  original  lesion  is  so 
completely  replaced  by  the  purulent  effusion,  that  the 
antecedent  local  conditions  can  only  be  inferred  from  the 
clinical  history  or  from  analogy ;  but  in  both  disorders  the 
vestiges  of  an  abnormal  pre-inflammatory  state  are  in 
many  cases  recognizable  after  the  inflammation  has  run  its 
course.  The  strict  limitation  of  a  meningitis  to  the  site  of 
a  meningeal  contusion  is  often  clearly  shown  in  cases  in 
which  infection  has  taken  place  through  a  cranial  opening, 
and  in  which,  while  the  membranes  in  the  vicinage  of  the 


PATHOLOGY.  69 

wound  present  a  perfectly  normal  appearance,  inflamma- 
tion has  been  localized  over  some  part  of  the  opposite 
hemisphere.  In  other  instances  there  are  two  or  more 
widely  separated  sites  of  subarachnoid  purulent  effusion, 
each  not  more  than  an  inch  in  diameter,  or  with  an  injury 
of  the  vertex,  a  single  one  of  no  greater  size  in  some 
region  of  the  base.  It  can  hardly  be  supposed  that  these 
multiple  or  distant  seats  of  inflammation  were  accidentally 
determined,  but  it  may  be  reasonably  assumed  that  their 
diminished  power  of  resistance  exposed  them  to  the  attack 
of  predatory  germs  and  hence  localized  the  pathogenic 
process.  There  are  few  recent  cases  in  which  traces  of 
meningeal  or  cerebral  contusion  do  not  confirm  this  as- 
sumption. The  demonstration  of  the  initial  lesion  in 
central  abscess  of  the  brain  is  often  prevented  by  the  pro- 
tracted course  of  the  disease,  but  even  after  the  lapse  of 
months  some  evidence  of  the  original  lesion  may  be  pos- 
sibly discovered  in  the  minute  examination  of  the  wall  of 
the  cavity.  The  position  of  the  abscess  is  always  signifi- 
cant. If  the  skull  has  been  fractured,  the  dura  wounded, 
and  the  surface  of  the  brain  lacerated  or  contused,  infec- 
tion will  be  followed  by  superficial  suppuration ;  if  the 
dura  remains  intact,  and  the  cerebral  surface  uninjured, 
the  pus  formation  will  occur  at  a  deeper  point  of  limited 
contusion  in  some  line  of  transmitted  force.  In  neglected 
pistol-shot  wounds  pus  may  form,  either  in  the  course  of 
or  upon  one  side  or  the  other  of  the  track  of  laceration, 
and  even  at  two  or  more  foci  of  inflammation.  The  severe 
contusion  of  the  adjacent  tissue  and  the  abundant  supply 
of  infective  material,  which  may  be  carried  to  any  depth 
into  the  intracranial  wound,  account  for  the  peculiar  situa- 
tion and  frequent  multiplication  of  abscess  in  cases  of  this 


70  INJURIES   OF   THE    BRAIN    AND    MEMBRANES. 

character.  The  lapse  of  time  from  the  reception  of  injury 
to  death  from  consequent  abscess  is  usually  so  consider- 
able that  not  only  the  indications  of  primary  lesion  may 
have  disappeared,  but  the  early  history,  if  it  was  ever 
noted,  is  ordinarily  lost.  A  mathematical  demonstration, 
therefore,  that  the  seat  of  central  abscess  of  the  brain  is 
always  the  site  of  an  original  contusion  or  laceration,  is 
even  more  difficult  than  in  case  of  meningeal  inflamma- 
tion. The  circumstances  which  tend  to  establish  it  infer- 
entially  are :  its  susceptibility  of  proof  whenever  satisfac- 
tory examination  is  possible ;  the  confirmation  afforded  by 
attainable  clinical  histories;  the  fact  that  it  is  not  directly 
propagated  from  the  point  at  which  violence  has  been 
inflicted;  and  the  greater  resistance  oft'ered  by  sound  tis- 
sue to  infection,  which  renders  already  damaged  parts  the 
natural  prey  of  wandering  pathogenic  germs.  The  neces- 
sity of  some  structural  injury  as  an  antecedent  condition 
of  the  establishment  of  either  meningeal  or  parenchyma- 
tous traumatic  inflammation  seems  scarcely  in  question. 
Either  one  of  the  meningeal  lesions,  whether  limited  or 
diffuse,  seems  to  be  adequate,  but  whether  diffuse  con- 
tusion always  precedes  diffuse  inflammation  is  uncertain. 
The  antecedent  visceral  lesions  are  subcortical  laceration 
and  limited  contusion ;  general  contusion  with  a  local  in- 
tensification may  possibly  be  included.  The  cortical  le- 
sions lead  to  superficial  abscess  only  when  directly  exposed 
to  infection ;  those  produced  upon  the  side  of  the  brain 
opposite  to  the  site  of  injury,  and  those  which  occur  with- 
out cranial  fracture,  are  thus  exempt  from  pyogenic 
change. 

The    immediate    dependence    of   these    inflammations 
upon    microbic    infection,  an    immigration    of   pathogenic 


\ 


\ 


PATHOLOGY.  7 1 

germs  from  without  or  from  some  other  part  of  the  body, 
has  been  proven  in  repeated  instance  by  cultures  of  the 
affected  tissue — in  so  many  instances  in  fact  that  the  only 
question  which  still  remains  is  whether  they  ever  originate 
without  foreign  intervention.  The  acceptance  of  the  prop- 
osition that  traumatic  intracranial  suppuration  is  even  gen- 
erally due  to  microbic  invasion  was  at  one  time  made 
unnecessarily  difficult  by  the  further  averment  that  trau- 
matic brain  abscess  never  occurs  without  external  wound. 
This  is  an  error  and  is  disproved  by  rather  more  than  ex- 
ceptional cases  :■  two  are  reported  by  the  author  in  a  previ- 
ous reference  to  the  subject.  The  knowledge  that  patho- 
genic germs  may  reach  the  brain  from  more  distant  points 
through  its  vascular  supply  renders  it  at  least  conceivable 
that  any  cerebral  abscess  -may  be  infective.  It  must  be 
conceded  that  in  by  far  the  greater  number  of  intracranial 
inflammations  of  traumatic  origin,  whatever  structure  may 
be  implicated,  there  has  been  wound  of  the  soft  parts 
which  invest  the  cranium.  The  external  lesion  may  be 
confined  to  the  tegumentary  coverings  of  the  bone,  but 
must  necessarily  involve  the  periosteum.  Simple  subperi- 
osteal exposure  of  the  osseous  surface,  erosion  or  wound  of 
the  bone,  punctured,  linear,  or  depressed  fracture,  in  the 
presence  of  pathogenic  organisms  may  each  lead  to  intra- 
cranial infection.  One  of  these  injuries  may  be  more 
probably  succeeded  by  infection  than  another,  as  the 
microbia  are  more  or  less  deeply  implanted,  or  otherwise 
more  or  less  inaccessible  to  germicidal  treatment.  In  the 
majority  of  instances,  danger  is  synonymous  with  neglect. 
The  osseous  surface  exposed,  eroded,  or  wounded,  or  the 
edges  of  a  compound  linear  fracture,  can  be  made  aseptic 
even  if  it  require  the  use  of  a  chisel,  and  the  elevation  of 


72  INJURIES   OF   THE    BRAIN    AND    MEMBRANES. 

a  depressed  fracture  affords  opportunity  for  the  destruction 
or  removal  of  lurking  elements  of  disease.  Fissures  of 
the  petrous  portion,  most  frequent  of  all  compound  cranial 
fractures,  can  be  made  absolutely  aseptic  by  careful  occlu- 
sion of  the  ear.  The  punctured  fracture  may  be  attended 
by  the  direct  introduction  of  pathogenic  germs  into  the 
cranial  cavity,  or  even  into  the  brain  substance,  which  are 
quite  beyond  the  reach  of  aggressive  measures;  but  the 
most  thorough  practicable  removal  of  tangible  foreign  sub- 
stances or  fragments  of  bone  and  cleansing  of  the  wound, 
and  the  most  vigorous  aseptic  care,  reduces  the  danger  of 
infection  to  exceedingly  narrow  limits ;  the  greatly  dimin- 
ished frequency  of  septic  inflammations  after  pistol-shot 
intracranial  wounds,  since  the  wider  recognition  of  the 
necessity  of  such  a  plan  of  treatment,  clearly  demonstrates 
how  much  can  be  accomplished  by  the  use  of  aseptic  and 
antiseptic  methods,  even  under  unfavorable  circumstances. 
The  most  inaccessible  osseous  lesions,  and  consequently 
when  infected  the  most  intractable,  are  fractures  through 
the  ethmoid  or  sphenoid  body,  or  of  the  occipital  basilar 
process,  with  wound  of  the  nasopharyngeal  mucous  mem- 
brane. It  is  not  only  impossible  to  subject  them  to  effi- 
cient aseptic  treatment,  but  they  are  peculiarly  exposed  to 
septic  influences  from  their  direct  communication  with 
both  the  digestive  and  respiratory  tracts.  In  the  usual 
instance  of  fracture  through  the  ethmoid  or  sphenoid  cells, 
derived  from  the  vault,  the  nasopharyngeal  membrane,  if 
wounded,  after  a  certain  amount  of  hemorrhage  is  likely 
to  be  closed  by  primary  union  and  danger  obviated ;  but 
in  gunshot  wounds  through  the  mouth,  if  the  patient  sur- 
vives, the  probability  of  infection  is  greatly  increased. 
Notwithstanding  the  various  possibilities  of  infection. 


PATHOLOGY.  73 

and  the  imperfection  of  aseptic  methods  as  they  are  ordi- 
narily employed,  the  actual  occurrence  of  traumatic  inflam- 
mation of  either  the  meninges  or  the  parenchyma  of  the 
brain  is  comparatively  infrequent.  In  the  appended  se- 
ries of  five  hundred  cases  of  intracranial  injury  of  diversi- 
fied character  there  are  included  but  three  central  abscesses 
and  one  of  the  cerebral  surface.  The  last  was  developed 
after  fracture  in  the  frontal  region  and  in  the  absence  of 
any  surgical  supervision,  and  one  of  the  others  had  run  its 
course  prior  to  admission  to  the  hospital  in  which  its  his- 
tory was  finally  recorded ;  there  remain  but  two  which  are 
fairly  chargeable  to  this  collection.  The  puffy  tumor  of 
Pott,  the  once  so  often  observed  cranial  necrosis  with 
underlying  abscess,  the  late  result  of  neglected  and  in- 
fected superficial  wound,  and  now  an  almost  extinct  sur- 
gical phenomenon,  is  unrepresented.  The  instances  of 
arachnitis  are  somewhat  more  numerous,  but  in  some  of 
these  an  infective  origin  was  not  demonstrable  upon  post- 
mortem examination ;  and  in  others  it  would  seem  that 
infection  should  have  been  prevented.  The  immediate 
treatment  of  these  cases  was  for  the  most  part  in  the  hands 
of  hospital  assistants  of  varying  degrees  of  capacity  and 
experience,  and  aseptic  methods,  while  employed  with  per- 
haps more  than  average  care,  were  not  always  ideal.  The 
infrequency  of  infective  inflammation,  therefore,  is  not  to 
be  ascribed  to  any  exceptional  rigor  in  aseptic  manage- 
ment. 

It  is  a  possibility  that  in  traumatic  inflammation  the 
pathogenic  organisms  should  reach  the  cranial  cavity 
through  other  channels  which  they  are  known  to  traverse 
in  idiopathic  cases,  as  through  the  tonsil,  or  Eustachian 
tube,  and  middle  ear,  or  in  the  general  circulation;    but 


74  INJURIES    OF   THE   BRAIN    AND    MEMBRANES. 

this  would  be  so  purely  a  coincidence,  and  so  unusual,  as 
to  require  no  special  consideration. 

There  is  no  reason  to  suppose  that  the  nature  of  the 
invading  germ  determines  the  site  of  infection.  Ingress 
having  been  obtained,  the  morbid  process  may  be  extended 
in  continuity  from  without,  or  may  be  established  at  a 
more  distant  point  which  has  been  made  vulnerable  by  the 
primary  injury.  In  this  relation,  the  views  of  Macewen, 
the  most  recent  writer  of  authority  upon  the  subject  of 
intracranial  inflammation,  have  been  abstracted  or  con- 
densed so  far  as  they  concern  the  conditions  of  septic  in- 
vasion and  the  degenerative  processes  by  which  they  are 
followed. 

"  In  a  ofiven  case  in  which  a  cause  of  infective  infiamma- 
tion  exists  on  the  outside  of  the  skull,  from  which  the  in- 
terior becomes  affected,  the  alternative,  whether  meningitis 
or  brain  abscess  results,  depends  partly  on  the  anatomical 
arrangement  of  the  structures  and  partly  on  the  intensity 
and  rapidity  of  the  inflammatory  action;  which  again  may 
be  dependent  upon  the  micro-organism  and  the  virulence 
of  its  action.  One — or  more — of  several  intracranial  con- 
ditions, pachymeningitis,  leptomeningitis,  ulceration  of 
the  brain,  abscess  of  the  brain,  and  necrosis  of  the  cere- 
bral tissue,  besides  the  involvement  of  the  intracranial 
sinuses  with  disintegrating  thrombosis,  may  result  there- 
from. 

"  TJic  various  intracranial  lesions  ii<hich  may  result  from 
pathoge7iic  and  saprophytic  causes,  and  the  manner  in  which 
organisms  reach  the  intracranial  structures: 

"  (i)  If  the  inflammatory  process  be  slow,  mild,  and  dis- 
tinctly localized,  involving  a  portion  of  the  inner  table  of 
the  skull,  then  an  external  pachymeningitis  may  form, 


PATHOLOGY.  75 

possibly  with  pus  between  the  dura  mater  and  the  bone, 
producing  an  extradural  abscess, 

"  (2)  Should  this  condition  persist,  adhesive  inflamma- 
tion is  apt  to  spread  to  the  inner  side  of  the  dura,  locally- 
soldering  it  to  the  subjacent  membranes  and  forming  a 
barrier  to  the  further  extension  of  inflammation. 

"  (3)  An  increase  of  inflammatory  action  may  induce  de- 
generative inflammation  with  softening  of  the  membranes 
and  of  the  previous  effusion,  followed  by  disintegration  of 
the  pia  and  superficial  ulceration  of  the  brain  tissue.  Two 
conditions  may  thus  result :  a  subdural  or  a  cortical  abscess, 
as  the  pia  remains  intact  or  as  it  suffers  purulent  soften- 
ing. In  either  case  the  abscess  is  at  first  localized,  but, 
should  the  disintegrating  process  involve  the  adherent 
membranes  forming  the  wall,  it  may  rupture  and  cause  an 
acute  leptomeningitis. 

"  (4)  If  the  cause  of  inflammation  extend  to  the  inner 
layer  of  the  dura  before  adhesion  of  the  membranes  has 
taken  place,  the  whole  subdural  space  is  open  to  invasion 
and  an  acute  far-reaching  leptomeningitis  is  apt  to  ensue. 

"  (5)  Leptomeningitis  and  cerebral  abscess  may  form 
independently  of  a  visible  tract  of  inflammation  spreading 
inward  from  the  initial  focus  of  irritation  outside  the  cra- 
nial cavity.  In  such  cases  the  pathogenic  cause  has  been 
conveyed  through  the  vascular  system  by  direct  extension 
from  the  source  of  infection.  This  may  be  done  by  a 
thrombosis  extending  through  the  veins  into  the  pia  or  the 
brain ;  or  the  veins  may  become  blocked  by  a  localized  dis- 
integrating thrombus,  portions  of  which  containing  patho- 
genic micro-organisms  may  be  carried  inward  by  the 
reversed  blood  stream,  which  is  permitted  by  the  absence 
of  valves  in  the  sinuses  and  intracranial  and  intra-osseous 


^6  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

veins,  and  is  termed  a  reflex  method  of  propagation.  In- 
fective matter  may  also  be  conveyed  into  the  brain  sub- 
stance through  the  perivascular  sheaths  of  the  arteries,  or 
partial  infective  and  disintegrating  thrombosis  may  form 
in  an  arterial  trunk,  and  particles  carried  into  terminal 
capillaries  occasion  minute  infective  hemorrhagic  extrava- 
sations with  resulting  abscess.  The  occlusion  of  a  large 
cerebral  artery  by  embolus  or  otherwise  causes  extensive 
necrosis.  Inflammation  again  may  spread  through  the 
lymphatics  or  along  the  course  of  the  perineural  sheaths. 

"  Micro-organisms  are  the  chief  cause  of  intracranial 
pyogenic  processes.  In  the  great  majority  if  not  in  all 
cases,  they  are  the  cause  of  both  leptomeningitis  and  brain 
abscess.  Whether  the  various  forms  of  intracranial  dis- 
ease have  each  a  distinct  specific  organism  which  produces 
it,  and  it  alone,  is  for  the  future  to  decide.  It  is,  how- 
ever, probable  that  the  same  organism  may  induce  several 
of  these  intracranial  lesions,  the  modifying  circumstances 
being  the  degree  of  its  action,  its  opportunities  of  access 
to  the  intracranial  contents  afforded  by  the  pathologico- 
anatomical  conditions  of  the  parts,  and  the  degree  of  the 
restraining  force  of  the  living  tissues  presented  by  the 
individual. 

"  The  pathogenic  organisms  found  in  suppurative  lepto- 
meningitis and  in  brain  abscess,  as  tested  both  by  the 
microscope  and  by  careful  plate  cultivation  in  the  author's 
cases,  have  most  frequently  been  the  streptococcus  pyo- 
genes and  the  staphylococcus  pyogenes  aureus.  Occa- 
sionally the  staphylococcus  pyogenes  citreus  and  albus  have 
been  discovered,  but  always  associated  with  one  of  those 
previously  mentioned.  A  great  variety  of  saprophytic 
organisms,    cocci   and    bacilli,    including    the    colon    and 


PATHOLOGY.  jy 

tubercle  bacillus,  odium  albicans,  and  the  diplococcus 
pneumoniae  of  Fraenkel,  have  been  found  in  more  or  less 
exceptional  cases  of  intracranial  suppuration. 

"Acute  Leptomeningitis. — When  acute  inflammation 
is  once  established  in  the  loose  arachnoid  mesh^vork,  it 
spreads  rapidly  and  widely  until  the  Avhole  cerebro-spinal, 
subdural,  and  intraventricular  spaces  are  involved,  as  well 
as  the  pia  mater,  and  in  some  instances  the  superficial  lay- 
ers of  the  brain.  The  sheaths  of  the  cranial  and  spinal 
nerves  are  likewise  implicated  for  a  considerable  distance 
outside  the  central  cavities.  When  pathogenic  micro- 
organisms are  inoculated  into  the  cerebro-spinal  fluid  they 
spread  with  remarkable  rapidity,  finding  a  suitable  tem- 
perature and  abundant  pabulum  for  their  development. 

"Acute  Serous  Leptomeningitis. — Hyperaemia  is  fol- 
lowed by  an  exudation  of  clear  serum,  often  containing 
flakes  of  fibrin,  and  occasionally  a  few  leucocytes,  and 
possibly  even  a  few  pus  corpuscles  in  the  perivascular 
sheaths  of  the  cortical  vessels.  The  serous  effusion  may 
be  so  abundant  and  so  rapidly  produced  as  to  cause  death 
from  compression,  and  when  it  persists  the  ventricles 
become  greatly  distended.  The  inflammation  may  be 
localized,  especially  when,  extending  from  without,  it  in- 
volves the  visceral  aspect  of  the  dura,  the  inner  membrane 
having  become  soldered  at  the  periphery  of  the  affected 
zone,  though  free  in  the  centre.  If  seen  through  a  tre- 
phine aperture  during  life,  many  of  the  minute  arteries 
seem  to  be  lifted  from  the  pia  mater,  as  if  floating  in  the 
clear  fluid  contained  in  the  almost  invisible  arachnoid 
meshwork,  but  are  probably  resting  on  the  outer  strands 
of  the '  osdematous  membrane.  The  arteries  are  far  more 
numerous    than    usually  represented,    and    the    veins    are 


78  IN'JURIES    OF    THE    BRAIN   AND    MEMBRANES. 

large  and  full.  The  pia  is  swollen,  oedematous,  and  much 
injected,  and  the  underlying  brain  is  moist  and  glistening. 
After  death  the  appearances  are  greatly  altered,  and  it  is 
often  difficult  to  find  by  the  naked  eye  sufficient  indica- 
tions to  account  for  the  fatal  termination ;  the  serum  is  apt 
to  escape  in  the  removal  of  the  calvarium,  there  are  few 
capillaries  in  the  meninges,  and  even  the  congestion  of 
the  white  substance  disappears  to  a  great  extent  from 
post-mortem  changes ;  the  only  indication  of  hyperasmia 
of  the  white  substance  is  distention  of  the  vessels. 

"  In  purulent  leptomeningitis,  besides  hypersemia  and 
serous  effusion,  there  is  great  exudation  of  leucocytes  into 
the  perivascular  spaces,  with  intense  dilatation  of  the 
veins,  their  periphery  being  marked  w4th  opaque  white 
and  yellow  exudation  caused  by  degeneration  of  leuco- 
cytes. The  coats  of  the  vessels  are  traversed  by  leuco- 
cytes, and  the  veins  are  frequently  plugged  with  granular 
coagula.  The  exudation  is  at  first  confined  to  the  arach- 
noid tissue  and  pia  matral  clefts  and  spaces.  It  may  ex- 
tend to  the  brain,  and  through  the  transverse  fissures  to 
the  telae  choroidae,  which  then  swell  and  become  covered 
with  pus  and  fibrino-purulent  exudation.  The  underlying 
brain  substance  is  then  moist  and  soft,  and  the  fluid  within 
the  ventricles  is  turbid  and  sero-purulent. 

"  If  the  inflammation  is  due  to  infective  causes,  there 
is  always  involvement  of  the  cerebral  tissue,  especially  the 
cortex,  which  undergoes  extensive  inflammatory  changes. 
These  may  extend  into  the  cerebral  cortex  by  the  pial 
sheaths  of  the  veins,  which  become  filled  with  leucocytes, 
or  there  may  be  direct  extension  of  the  inflammation,  facil- 
itated by  prior  adhesions  of  the  membranes.  In  such  cases 
the  nerve  tissue  of  the  brain  and  cord  is  often  infiltrated 


PATHOLOGY.  79 

with  cells.  Accompanying  the  purulent  meningitis  there 
is  frequently  implication  of  the  interior  of  the  brain  in  the 
form  of  minute  extravasations  in  the  perivascular  sheaths, 
and  larger  ones  in  the  cerebral  tissue ;  the  latter  being 
generally  surrounded  by  an  area  of  cerebral  softening, 
which  areas  may  ultimately  be  the  seats  of  purulent  exu- 
dation. 

"  In  the  formation  of  purulent  encephalitis,  besides  the 
swelling  of  the  cerebral  substance,  there  is  excessive  se- 
rous and  leucocytal  exudation,  and  extravasations  of  red 
blood  corpuscles,  which  are  of  very  frequent  occurrence  in 
acute  inflammation  of  the  brain. 

"Red  softening  is  a  condition  occasioned  by  the  coales- 
cence of  many  of  these  minute  hemorrhages.  The  red 
corpuscles  are  effused  into  the  perivascular  sheaths  or  into 
the  brain  tissue  itself  and  are  soon  followed  by  leucocytes, 
which  are  exuded  in  large  numbers  from  the  vessels. 
The  affected  area  of  the  brain  is  swollen  and  oedematous, 
and  on  section  projects  above  the  level  of  the  healthy 
structure.  As  the  exudation  continues,  the  nerve  tissue 
degenerates ;  a  process  of  molecular  disintegration  ensues, 
in  which  the  minute  particles  of  brain  tissue  become 
mixed  with  the  disintegrating  leucocytes  which  have 
formed  into  pus  cells. 

**  White  softening  is  a  condition  in  which,  with  very  little 
hemorrhagic  extravasation,  a  primary  leucocytal  exudation 
passes  directly  into  pus  production  and  molecular  disinte- 
gration, as  above  described.  Pathogenic  embolism  in  a 
cerebral  artery  or  vein  of  the  white  substance  occasions 
hemorrhagic  extravasation,  accompanied  or  shortly  fol- 
lowed by  an  exudation  of  leucocytes,  which  infiltrate  the 
extravasation  and  contiguous  brain  tissue.     These  leuco- 


8o  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

cytes  rapidly  degenerate  into  pus,  while  the  neighboring 
nerve  tissue  disintegrates  and  liquefies.  These  emboli 
may  be  accompanied  by  anaemic  or  hemorrhagic  necrosis, 
as  an  artery  or  a  vein  has  been  blocked.  This  may  be  in- 
dicated by  the  parts  during  operation:  when  they  are 
oedematous  and  glistening  they  are  anaemic,  and  therefore 
due  to  arterial  thrombosis ;  and  when  they  appear  as  red- 
dish-brown sloughs  they  are  hemorrhagic,  and  due  to 
venous  thrombosis.  When  large  arteries  are  blocked,  a 
necrosis  of  extensive  area  may  occur,  which  may  be  after- 
ward separated.  Such  large  necrotic  portions  may  also 
arise  from  very  acute  and  infective  inflammation. 

"Cerebral  Abscess. — The  pus  contained  varies  much  in 
color  and  consistence.  When  mingled  with  much  disinte- 
grated tisue  w'hich  has  been  infiltrated  with  extravasations 
of  blood,  it  is  of  a  dark-brown  color;  when  free  from  such 
extravasations  it  is  greenish-yellow  in  color,  probably 
from  the  presence  of  the  bacillus  pyocyaneus;  when 
very  foetid,  it  is  thin,  serous,  and  generally  contains 
many  minute  sloughs,  and  when  connected  with  dis- 
ease of  the  middle  ear  may  also  contain  the  bacillus 
pyogenes  foetidus.  Micrococci  are  abundant,  especially 
at  an  early  period. 

"Peripheral  Changes. — The  vessels  of  the  tissue  sur- 
rounding and  forming  the  boundary  of  an  acute  abscess 
may  be  seen  in  all  stages  of  inflammation,  from  hyper- 
aemia  in  the  outer  zone  to  thrombosis  in  the  inner.  Sur- 
rounding the  vessels  are  masses  of  exudation  cells,  mingled 
w4th  extravasated  red  corpuscles;  and  the  glimpses  of 
brain  tissue  which  may  be  had  in  the  less  inflamed  parts 
show  it  to  be  softened  and  disintegrating.  When  the  in- 
flammation has  been  great,  the  vessels  are  scarcely  recog- 


PATHOLOGY.  8 1 

nizable,  on  account  of  the  exudation  cells  not  only  filling 
the  surrounding  parts  but  also  the  vessel  wall  and  in  great 
measure  occupying  its  interior,  the  red  corpuscles  being 
faintly  seen  in  some,  while  in  others  they  have  entirely 
disappeared.  Irregularly  distributed  over  the  surface  of 
the  abscess  are  minute  sloughs  of  an  oedematous,  grayish 
appearance,  with  pus  in  their  periphery  and  in  the  pockets 
and  sinuosities  in  the  abscess  wall.  The  surface  toward 
the  abscess  is  flocculent,  shaggy,  and  irregular  in  outline, 
with  occasional  little  naked  thrombosed  vessels  projecting 
into  the  cavity.  As  in  a  process  of  ulceration  in  other 
parts  of  the  body,  the  small  vessels  become  thrombosed  in 
advance  of  the  molecular  necrosis,  and  so  hemorrhage  into 
the  abscess  is  usually  prevented.  The  zone  of  peripheral 
brain  tissue  is  oedematous  and  its  vessels  are  hyperaemic. 
There  is  thus  no  other  wall  of  an  acute  abscess  than  a 
softened  and  disintegrated  tissue  filled  with  exudation 
cells  and  extravasated  blood. 

"  The  pia  and  arachnoid  over  an  area  of  degeneration 
have  often  a  milky  or  turbid  appearance. 

"  Encapsulation When  the  process  of  molecular  disin- 
tegration ceases,  and  the  brain  tissue  possesses  sufficient 
vitality  to  assume  a  formative  action,  the  debris  of  disinte- 
grated granular  cells,  leucocytes,  blood,  and  inspissated 
pus,  becomes  entangled  in  the  meshes  of  fibrin,  the  ele- 
ments for  the  formation  of  which  are  poured  out  from  the 
living  tissue.  Into  this  mass  large  numbers  of  leucocytes 
penetrate,  some  of  which  form  bundles  of  elongated  spin- 
dle cells.  Later  a  few  blood-vessels  of  the  most  primitive 
description  project  from  the  living  tissue  into  the  mem- 
brane and  supply  nutriment  to  the  leucocytes  in  their  im- 
mediate neighborhood.     The  pus  thus  becomes  encapsu- 


82  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

lated  by  a  layer  of  membrane  of  very  low  vitality,  which 
shuts  off  the  living  brain  tissue  from  the  dead  pus  within. 
The  abscess  thus  becomes  to  a  great  extent  stationary; 
first,  because  the  process  of  molecular  degeneration  has 
ceased,  and  second,  because  the  leucocytes  which  penetrate 
for  some  way  into  the  living  wall  of  the  abscess,  and  which 
might  be  converted  into  pus  were  they  shed  on  the  inside 
of  the  capsule,  are  principally  caught  by  the  meshwork  of 
fibrin,  so  that  few  pass  into  the  abscess  cavity.  As  the 
lining  membrane  thickens,  the  difficulties  of  the  transmi- 
gration of  leucocytes  increase,  both  on  account  of  the  great 
distance  they  have  to  travel  and  the  continued  formation 
of  fibrous-tissue  bundles.  Thirdly,  this  membrane,  though 
it  permits  the  passage  of  serum  from  the  pus  cavity  to  the 
vessels  of  the  living  tissue,  yet  prevents  the  absorption  of 
the  particulate  portions  of  the  disintegrated  pus.  The 
capsule,  from  one  to  five  or  more  millimetres  in  thickness, 
is  generally  smooth  internally  and  rather  ragged  and  floc- 
culent  externally,  and  more  regular  in  outline  than  the 
boundary  of  the  acute  abscess. 

*'  Absorption. — A  cerebral  abscess  may  become  absorbed 
from  changes  which  take  place  in  its  wall  from  the  side  of 
the  living  tissue.  The  circumferential  pressure  of  the 
brain  may  facilitate  absorption  of  the  fluid  portion  of  the 
pus,  while  well-formed  vessels  may  be  thrown  out  from 
the  living  brain  tissue,  and  penetrating  the  capsule  may 
thus  aid  in  the  absorption  of  pus  debris  through  phago- 
cytic action.  In  this  way  a  considerable  portion  of  a  small 
abscess  may  become  absorbed. 

**  Growth  from  within  is  possible  if  the  capsule  be  re- 
placed in  part  by  a  layer  of  vigorous  granulation  tissue,  a 
fresh  supply  of  pus  being  formed,  which  may  augment  the 


PATHOLOGY.  83 

size  of  the  abscess  and  exercise  pressure  from  within  upon 
the  capsule,  which  thus  becomes  thinned  in  parts.  The 
abscess  may  then  burst  either  into  the  ventricles  or  into 
the  subdural  space. 

"  Discharge* — Abscesses  may  empty  themselves  exter- 
nally through  the  tegmen  tympani,  cribriform  ethmoidal 
plate,  or  posterior  condyloid  foramen,  by  adhesion  of  the 
membranes  and  absorption  of  intervening  brain  tissue. 
They  may  also  break  into  the  subdural  tissue  or  into  the  ven- 
tricles, causing  acute  suppurative  leptomeningitis,  which 
in  the  subdural  space  may  be  limited  by  membranous  ad- 
hesions previously  established. 

"Secondary  abscess  may  form  in  the  periphery  of  one 
already  encapsulated.  Neighboring  tissues  are  not  always 
tolerant;  compression  may  induce  degeneration  and  atro- 
phy; slight  causes  may  then  occasion  fresh  oedema  and 
inflammation,  which  becomes  purulent.  It  is  probable, 
however,  that  a  leakage  of  the  contents  of  the  abscess  into 
the  compressed  tissues  in  the  vicinity  may  set  free  micro- 
organisms which  regain  their  vitality  and  excite  a  fresh 
inflammation.  In  such  case  the  original  abscess  may 
sometimes  be  found  floating  in  the  pus  of  the  one  consecu- 
tively established. 

'*  Pyaemic  abscess  may  be  caused  by  septic  matter  origi- 
nating in  some  distant  source,  in  any  part  of  the  body,  and 
carried  in  the  blood  stream  until  deposited  in  a  small  ves- 
sel producing  infective  embolism.  Disintegrating  pneu- 
monia, foetid  bronchitis,  pericarditis,  or  empyema,  and 
infected  compound  fractures,  are  among  the  diseases  and 
injuries  from  which  it  is  derived.  It  is  multiple  in  two- 
thirds  of  the  cases  in  which  it  occurs,  and  it  invades  both 
cerebrum  and  cerebellum.     Traumatic  abscesses  are  single 


84  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

in  ninety-three  per  cent.,  and  are  usually  situated  in  the 
frontal  or  parietal  lobe. 

"After  an  abscess  has  been  evacuated,  the  brain  tissue 
tends  to  fill  the  gap ;  if  the  abscess  be  acute,  a  few  hours 
suffice ;  if  it  be  chronic,  it  may  be  days  before  the  cavity  is 
obliterated.  When  the  brain  has  been  once  closed  by  the 
resiliency  of  the  brain  tissue,  there  is  a  probability  that 
the  brain,  while  more  or  less  fixed  to  the  dura,  will  remain 
otherwise  free  from  adhesions.  When  the  wound  heals  by 
granulation  tissue,  the  pia  mater  adheres  to  the  cicatrix, 
soldering  the  brain  to  what  becomes  a  rigid  wall.  Such 
an  anchoring  of  the  brain  is  left  subsequently  to  produce  a 
shock  on  sudden  movement,  as  on  rising  from  a  recumbent 
or  sitting  position,  causing  unconsciousness,  generally  of 
brief  duration.  This,  when  frequently  repeated,  may  in 
time  produce  encephalitis  over  an  extended  area. 

"Occasionally  a  depression  filled  with  serum,  rarely 
with  cerebro-spinal  fluid,  remains  upon  the  brain  surface 
over  the  site  of  the  former  abscess. 

"  Necrosis  of  a  portion  of  cerebral  tissue  may  be  caused : 
(i)  by  infective  embolism  or  thrombosis  of  the  main  artery 
supplying  a  portion  of  the  brain,  resulting  in  anaemic  gan- 
grene; (2)  by  embolism  of  the  main  veins,  with  hemor- 
rhagic necrosis ;  (3)  occasionally  by  localized  pressure  by 
a  part  engorged  by  extravasations,  which  may  lead  to  dis- 
organization and  death  of  neighboring  brain  tissue ;  (4)  by 
intensity  of  inflammatory  action  due  to  the  nature  of  the 
micro-organism." 

This  somewhat  extended  summary  of  Mace  wen's  ac- 
count of  the  infective  intracranial  inflammations  is  justi- 
fied by  the  completeness  and  accuracy  with  which  he  has 
traced  their  pathic  relations,  and  the  attempt  to  rewrite 


PATHOLOGY.  85 

their  history  could  be  made  successful  only  by  trenching 
largely  upon  the  mass  of  fact  and  inference  which  he  has 
so  adequately  presented.  There  are  certain  considera- 
tions, however,  which  especially  pertain  to  cases  of  trau- 
matic origin,  to  which  attention  may  be  further  directed. 
In  this  restricted  class,  it  is  the  localization  of  the  initial 
lesion,  whether  laceration  or  limited  contusion,  which  de- 
termines the  alternative  of  arachnitis  or  cerebral  abscess, 
rather  than  the  anatomical  structure,  grade  of  inflamma- 
tory action,  or  peculiarities  in  the  nature  of  micro-organ- 
isms, to  which  Macewen  in  his  study  of  intracranial  inflam- 
mation attributes  the  occurrence  of  pyogenic  processes  in 
one  tissue  in  preference  to  another.  The  contention  that 
the  site  of  election  for  these  inflammations  is  in  the  part 
which  has  been  weakened  by  wound  or  bruise,  and  thus 
invites  attack  from  pathogenic  germs,  or  succumbs  to 
pathic  processes  already  established,  was  made  in  the  orig- 
inal publication  of  a  case  of  cerebral  abscess,"^  Xo.  XXXII, 
in  the  present  series.  In  this  instance,  in  which  death 
occurred  at  an  early  period,  the  formation  of  abscess  at  the 
site  of  a  subcortical  contusion  was  demonstrable.  The 
point  of  invasion  having  been  determined,  the  extension 
of  the  disease,  its  intensity,  the  conditions  of  its  develop- 
ment and  progress,  may  be  conceivably  controlled  by  the 
virulence  and  extent  of  the  microbic  infection,  or  influ- 
enced by  the  structural  characteristics  of  the  tissue  in- 
volved. 

The  traumatic  intracranial  infections  have  been  practi- 
cally limited  to  the  two  which  have  been  specifically  men- 
tioned— arachnitis  and  cerebral  abscess — both  arising  at  a 
point  distant  from  the  cranial  wound,  if  one  chances  to 

*  New  York  Medical  Journal,  vol.  li.,  Xo.  13,  iSgi. 


86  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

exist.  The  occurrence  of  the  several  forms  of  pachymen- 
ingitis and  arachnitis,  and  the  formation  of  subdural  and 
cortical  abscess,  through  the  spreading  of  an  inflammatory 
process  by  continuity  from  an  infected  external  wound, 
though  still  possible,  is  in  the  highest  degree  improbable, 
except  as  the  result  of  gross  ignorance  or  neglect.  A  dif- 
fuse purulent  inflammation  of  the  brain  substance,  which 
may  follow  the  use  of  drainage  tubes,  is  probably  un- 
known, as  is  red  softening  as  an  effect  of  violence.  All 
these  conditions  may  occur  in  connection  with  cases  of 
otitis  media,  from  which'a  knowledge  of  the  phenomena  of 
intracranial  infection  has  been  so  largely  derived.  In 
traumatic  infection  the  micro-organism  finds  access  to  the 
cranial  cavity  through  a  direct  breach  of  its  walls,  traverses 
some  one  of  the  several  channels  which  have  been  enume- 
rated, and  discovers  for  attack  that  part  of  the  brain  or 
meninges  in  which  resistance  has  been  minimized  by  pre- 
vious injury  and  to  which,  in  the  brain  at  least,  the  morbid 
process  is  confined.  The  possibility  of  accidental  infec- 
tion through  the  general  circulation  without  superficial 
wound  is  too  remote  to  be  taken  into  account. 

The  question  whether  these  inflammations  can  arise 
from  traumatism  alone,  in  the  absence  of  a  secondary  in- 
fection, has  remained  unsolved.  There  is  no  doubt  that 
an  arachnitis  of  the  subacute  form  occurs  in  this  way,  for 
it  has  been  often  found  to  be  amicrobic  when  cultures 
have  been  made  from  its  effusion ;  but  the  streptococcus 
pyogenes  has  also  been  detected  in  arachnoid  exudations 
which  were  but  slightly  turbid.  There  is  no  similar  evi- 
dence attainable  that  acute  arachnitis  is  ever  non-infective, 
and  the  same  is  true  in  the  case  of  cerebral  abscess. 
There  are  probably  no  recorded  instances  in  which  culture 


PATHOLOGY.  8/ 

examination  of  the  pus  of  either  inflammatory  process  has 
failed  to  disclose  the  presence  of  pathogenic  organisms. 
It  should  be  said  at  the  same  time  that  comparatively  few 
cases  are  subjected  to  this  test,  for  which  facilities  are 
usually  wanting;  nor  is  it  necessary  to  regard  infection  as 
an  essential  condition  of  suppuration.  Pus  is  demon- 
strably formed  elsewhere  without  microbic  intervention, 
and  there  is  no  reason  why  it  might  not  be  so  formed 
equally  well  in  the  cranial  cavity.  The  occasional  occur- 
rence of  purulent  arachnitis,  or  of  brain  abscess  from  head 
injury  in  which  no  superficial  wound  or  cranial  fracture 
has  been  involved,  adds  to  the  probability  that  such  is 
sometimes  the  case. 

The  occurrence  of  araicrobic  inflammation  is  ascribed 
by  Gouley  to  the  irritation  of  dead  atoms  which  have  failed 
of  absorption.  It  may  happen  that  "  individual  human 
cells  undergo  nutritional  alterations,  or  even  starve  to 
death  from  insufficient  pabulum,  or  from  its  exclusion  by 
the  sudden  plugging  of  a  neighboring  vessel,  and  are  cast 
away  if  there  be  a  proper  channel  for  their  exit ;  or  other- 
wise may  be  devoured  by  leucocytes,  or  taken  up  as  effete 
material  and  excreted."  In  the  case  of  intracranial  con- 
tusion the  capillary  obstruction  may  thus  lead  to  molecular 
death  of  meningeal  or  cerebral  tissue,  which  is  ordinarily 
followed  by  direct  absorption  and  excretion ;  or  in  excep- 
tional cases,  in  the  absence  of  infection,  the  dead  tissues, 
like  micro-organisms  or  other  foreign  matter,  may  remain, 
to  be  at  "once  attacked  by  migrated  leucocytes  which 
strive  to  ingest  and  digest  the  offending  substance,  or  it 
may  chance  that  many  of  these  leucocytes  die  in  the  strug- 
gle, or  are  so  numerous  as  to  crowd  themselves  to  death, 
and  form  what  is  called  pus."     This  explanation,  which  is 


88  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

based  in  part  upon  Bland  Sutton's  theory  of  inflammation, 
is  adequate  to  the  comprehension  of  a  non-infective  pyo- 
genic process.  Any  foreign  particles,  whether  exanimate 
atoms  of  tissue  or  microbia,  may  be  sufficient  as  irritants 
to  excite  the  initial  migration  of  leucocytes.  If  the  ami- 
crobic  pyogenic  process  rarely  or  never  occurs  as  a  result 
of  intracranial  lesion,  it  is  because  molecular  necrosis  is 
insignificant  and  absorption  immediate,  or  because  the 
leucocytal  host  is  victorious  in  attack. 

The  conditions  which  favor  or  determine  the  event  of 
a  subacute  amicrobic  arachnitis  as  a  sequel  of  meningeal 
contusion  are  uncertain.  Age,  previous  habits,  or  consti- 
tutional condition  have  no  recognizable  influence,  and  it 
seems  to  be  independent  of  the  nature  of  coexistent  le- 
sions. Its  invasion  is  usually  late,  and  its  general  history 
is  best  interpreted  upon  the  supposition  that,  engrafted 
upon  the  primary  tissue  changes,  its  development  is  in  the 
usual  course  of  idiopathic  secondary  serous  inflammations 
in  prolonged  disease. 

The  use  of  the  term  arachnitis  in  place  of  leptomenin- 
gitis is  a  reversion  to  a  more  exact  nomenclature,  and  was 
suggested  by  Alonzo  Clark  some  years  ago  on  the  ground 
of  anatomical  propriety.  The  pia  mater  is  merely  a  sub- 
serous tissue  in  which  the  nutrient  vessels  subdivide,  and 
is  analogous  to  the  subjacent  tissue  which  contains  the 
vessels  of  the  pleura  or  the  peritoneum.  The  inflamma- 
tion, which  is  the  sum  of  certain  irritant  vascular  disturb- 
ances in  this  structure,  is  an  arachnitis,  as  similar  changes 
in  the  pleural  or  peritoneal  subserous  tissue  constitute  a 
pleurisy  or  a  peritonitis.  The  fact  that  the  exudation 
occurs  upon  the  attached  rather  than  upon  the  free  surface 
of  the  serous  membrane,  in  this  instance  is  only  an  acci- 


PATHOLOGY.  89 

dent  dependent  upon  its  exceptional  looseness  of  attach- 
ment. 

Reference  is  often  made  to  a  supposed  result  of  intra- 
cranial injury,  whicli  is  designated  encephalitis.  In  a 
proper  sense  of  the  word  no  such  condition  exists.  A 
pyogenic  inflammation  may  extend  from  an  infected  cra- 
nial wound  through  the  meninges  and  include  the  cortex, 
or  a  similar  process  in  a  portion  of  the  brain  substance 
may  reach  the  meninges,  and  in  an  arachnitis  the  contigu- 
ous brain  surface  may  also  be  infiltrated  with  cells ;  but  a 
concurrent  general  inflammation  of  the  several  intracranial 
structures  is  unknown,  from  any  definitely  recorded  obser- 
vation. The  term  is  usually  employed  as  a  synonym  for 
cerebritis  or  phrenitis,  which  are  equally  apocryphal.  A 
pyogenic  process  is  evidently  not  implied,  but  a  simple 
cellular  infiltration  of  the  whole,  or  of  some  considerable 
portion,  of  the  parenchyma.  In  a  minute  structural  exam- 
ination of  many  hyperasmic  and  oedematous  brains,  taken 
from  patients  who  had  survived  injury  for  some  days  or 
weeks,  no  evidence  of  such  a  form  of  inflammation  has 
been  discovered.  The  vague  descriptions  of  traumatic 
cerebritis  or  encephalitis,  which  are  encountered  from  time 
to  time,  are  never  consistent  with  such  a  disease  or  veri- 
fied by  necropsy,  and  are  to  be  regarded  as  no  more  than 
a  misapplication  of  words  or  pure  assumption. 

There  is  a  very  exceptional  form  of  brain  inflammation 
which  is  not  pyogenic,  and  is  not  of  the  class  of  pseudo- 
inflammations  just  mentioned.  It  is  of  a  cirrhotic  charac- 
ter and  results  in  a  true  atrophy  of  the  part  involved. 
The  leucocytes,  which  have  invaded  the  region  of  injury 
and  successfully  destroyed  the  irritant  necrotic  or  other 
foreign  matter  which  led  to  their  migration,  are  under 


go  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

certain  unknown  conditions  formed  into  a  new  and  con- 
tractile tissue  in  place  of  undergoing  the  usual  process  of 
fatty  degeneration  and  absorption.  It  has  been  produced 
incidentally  in  experimental  needle  punctures,  but  is  so 
nearly  unknown  clinically  that  its  history  cannot  yet  be 
written.  The  appended  series  of  cases  contains  a  single 
instance,  which  is  the  only  one  within  the  knowledge  of 
the  writer.  This  was  observed  in  a  necropsy,  seven 
months  after  the  reception  of  injury,  and  was  confined  to 
the  right  temporal  lobe,  which  was  indurated  and  reduced 
to  not  more  than  from  one-half  to  one-third  its  normal  size ; 
the  original  nerve  tissue  had  largely  disappeared ;  an  exten- 
sive laceration  existed  upon  its  inferior  surface  which 
presented  no  evidence  of  the  beginning  of  repair.  The 
patient  had  suffered  a  convulsion  on  the  fifteenth  day  after 
injury,  and  was  without  further  symptoms  until  subjected 
to  an  operation  for  fractured  patella  six  months  afterward. 
This  was  followed  by  severe  convulsions  and  wild  delirium, 
which  recurred  one  month  later  and  occasioned  death  from 
exhaustion.  Laceration  was  the  prominent  lesion,  but  the 
secondary  interstitial  inflammation  which  supervened 
might  equally  well  have  resulted  from  a  concomitant 
regional  contusion  of  this  lobe.  The  convulsions  which 
marked  the  progress  and  termination  of  the  case  seem  to 
have  been  directly  symptomatic,  but,  as  will  be  established 
later  in  a  study  of  symptoms,  convulsions  are  character- 
istic of  laceration  of  the  same  part ;  the  seat  rather  than 
the  nature  of  the  lesion  is  likely  to  have  determined  their 
occurrence. 


chapter   II. 

SYMPTOMATOLOGY. 

DIRECT    LESIONS. 

The  intrinsic  difficulty  which  has  been  encountered  in 
the  interpretation  of  symptoms,  resides  in  the  usual  com- 
plexity of  lesions,  and  has  been  increased  by  their  appar- 
ent identity  in  cases  in  which  dissimilar  pathic  conditions 
have  been  found  to  exist.  It  is  necessary  at  the  outset  to 
recognize  the  fact  that  without  exception  they  result  from 
demonstrable  organic  change.  It  is  also  essential  to  dis- 
card the  use  of  comprehensive  terms  by  which  it  is  sought 
to  group  or  to  contrast  symptoms  without  reference  to  the 
structural  alterations  upon  which  they  depend.  In  this 
way  concussion,  encephalitis,  and  compression  will  be 
eliminated  from  consideration  and  the  study  of  symptoms 
greatly  simplified.  The  prevalence  of  erroneous  views  of 
pathology,  and  unwarranted  or  faulty  generalizations  in 
symptomatology,  with  the  force  which  they  derive  from 
prescription,  may  be  reckoned  extrinsic  causes  of  diagnos- 
tic uncertainty. 

As  each  form  of  intracranial  injury  is  attended  by  char- 
acteristic outward  manifestations,  and  as  no  evidence  ex- 
ists that  these  occur  independently  of  anatomical  change, 
symptoms  should  be  grouped  under  the  name  of  their 
pathogenic  lesion.  Any  other  classification  of  traumatisms 
is  arbitrary,  misleading,  unphilosophical,  and  contrary  to 
accepted  principles  of   nosology.     These   intracranial   le- 


92  I^7URIES    OF   THE    BRAIN   AND    MEMBRANES. 

sions,  reaffirmed  in  brief  and  arranged  with  reference  to 
their  clinical  indications,  are:  i.  Hemorrhages.  2.  Dif- 
fuse and  limited  contusion  of  the  brain.  3.  Laceration  of 
the  brain.  4.  Secondary  inflammations  of  the  brain  and 
arachnoid  membrane,  which  are  almost  invariably  pyo- 
genic. 

Meningeal  contusion  is  either  merged  in  a  general  con- 
tusion of  the  brain  substance  or  results  in  a  hemorrhage  or 
inflammation,  which  may  be  considered  in  connection  with 
the  same  conditions  arising  from  other  lesions. 

The  exclusion  from  consideration  of  purely  hypotheti- 
cal disorders,  the  establishment  of  an  absolute  dependence 
of  symptoms  upon  demonstrated  lesions,  and  the  adoption 
of  an  exact  anatomical  classification  of  these  traumatic 
morbid  conditions  go  far  toward  making  their  symptoma- 
tology comprehensible.  The  difficulty  which  remains, 
arising  from  a  concurrence  of  lesions  with  or  without  simi- 
larities in  outward  expression,  is  to  be  met  by  the  study  of 
cases  in  which  the  lesion  is  single,  or  in  which  one  of  sev- 
eral is  primary  and  of  paramount  importance.  The  knowl- 
edge thus  gained  may  be  applied  to  the  elucidation  of  more 
complicated  traumatisms. 

I.  Hemorrhages. 

The  general  impression  as  to  the  exceeding  frequency 
of  hemorrhage  in  intracranial  injury  is  justified  by  an  ex- 
amination of  the  appended  series  of  cases.  In  from  fifty 
per  cent,  to  sixty  per  cent,  it  occurred  in  sufficient  quan- 
tity and  in  such  relation  as  largely  to  influence  the  final 
result,  and  to  become  a  determinate  factor  in  the  genesis 
of  symptoms.  In  one-third  of  this  percentage  it  was  the 
direct  if  not  the  sole  cause  of  a  fatal  termination.     In  a 


SYMPTOMATOLOGY.  93 

very  large  proportion  of  the  whole  number  it  was  second- 
ary to  laceration,  and  while  this  was  in  itself  often  insig- 
nificant, the  hemorrhage  was  none  the  less  profuse  and  the 
source  of  both  symptoms  and  danger.  In  the  residue  of 
cases  in  which  it  was  primary,  it  was  associated  with  some 
degree  of  other  structural  alteration.  The  opinion  has 
been  already  expressed  that  in  all  intracranial  injuries  a 
certain  amount  of  general  contusion  of  the  brain  substance 
will  be  found  to  exist,  and  in  few  of  these  necropsies  was 
it  so  slight  as  to  seem  unimportant.  There  are,  however, 
many  instances  in  which  hemorrhage  is  the  essential  lesion 
and  which  may  afford  sufficient  ground  for  inductive  ex- 
amination. Thirty-one  such  cases  have  been  selected  for 
analysis ;  they  comprise  eighteen  of  epidural  and  thirteen 
of  pial  origin.  Eight  recovering  cases,  in  which  the  ex- 
istence of  hemorrhage  was  verified  by  operation  and  in 
which  no  considerable  complication  existed,  have  been 
added,  making  a  total  number  of  thirty-nine.  Some  of 
the  necropsic  cases  have  been  included,  notwithstanding 
the  existence  of  a  well-marked  cerebral  contusion,  because 
the  hemorrhage  was  large  and  its  symptoms  likely  to  be 
characteristic. 

The  one  constant  symptom  in  fatal  cases  was  some  de- 
gree of  unconsciousness.  In  the  majority  it  was  profound, 
or  at  least  complete,  from  the  moment  of  injury  to  the  end 
of  life.  In  five  others  consciousness  was  primarily  lost, 
and  after  more  or  less  complete  restoration  was  merged  in 
final  coma.  In  four  instances  consciousness  was  retained 
for  some  length  of  time,  during  which  the  patient  walked 
for  a  considerable  distance,  and  then  either  gradually  or 
suddenly  became  unconscious.  In  two  cases  of  late  un- 
consciousness, delirium  followed  and  continued  till  death 


94  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

occurred;  and  in  two  others,  in  which  unconsciousness 
was  primary,  delirium  followed  hard  upon  it  without  a 
period  of  conscious  intelligence.  In  the  operative  cases, 
in  which  recovery  ensued,  and  in  which  it  is  fair  to  assume 
that  the  effusion  was  smaller,  loss  of  consciousness  was 
less  constant,  occurring  in  but  half  their  number.  In  two 
the  mental  condition  remained  unaffected,  and  in  one  un- 
consciousness was  replaced  by  delirium.  Of  three  cases 
in  which  delirium  was  a  symptom,  it  was  very  transitory 
in  two,  and  in  one  but  moderately  prolonged. 

The  varying  phases  of  unconsciousness,  the  diverse 
symptomatic  conditions  with  which  it  is  associated,  and 
the  uncertain  period  of  its  occurrence,  render  it  impossible 
to  accept  the  traditional  explanation  of  its  existence,  that 
it  is  solely  dependent  upon  a  mechanical  compression  of 
the  subjacent  brain  substance  by  the  blood  which  has  been 
extravasated.  It  is  probable  that  as  a  primary  symptom — 
as  an  instantaneous  result  of  injury — it  is  due  to  general 
cerebral  contusion,  which  is  itself  an  instantaneous  lesion. 
It  has  been  seen  that  in  the  larger  number  of  the  fatal 
cases  collated  it  has  been  absolutely  the  first  symptom,  not 
only  at  the  time  of  admission  but  as  learned  at  the  scene 
of  accident  and  noted  in  the  ambulance  history.  The 
effusion  of  a  sufficient  amount  of  blood  to  act  mechanically 
requires  an  appreciable  interval.  This  is  evident  in  cer- 
tain of  the  cases  of  rupture  of  the  arteria  meningea  media, 
in  which  some  hours  elapsed  before  the  patient  became 
unconscious,  and  in  which  the  epidural  clot  was  found  to 
be  of  enormous  size.  There  may  or  may  not  be  a  restora- 
tion of  the  intellectual  faculties  between  the  earlier  and 
the  later  phases  of  consciousness.  The  general  cerebral 
contusion  may  be  so  severe  that  the  unconsciousness  which 


SYMPTOMATOLOGY.  95 

it  produces  will  continue  till  the  effusion  has  become  suffi- 
cient to  occasion  the  same  condition,  and  one  is  lost  in  the 
ether.  It  is  also  possible  that  the  central  lesion  may  be 
insufficient  to  annul  consciousness  for  the  time  necessary 
to  the  eff'usion  of  blood  in  sufficient  quantity  to  act  as  an 
immediate  stupefying  agent,  and  there  is  no  primary  men- 
tal obscuration.  This  opinion  as  to  the  manner  in  which 
loss  of  consciousness  occurs  in  intracranial  lesions  will  be 
strengthened  by  the  wider  comparison  of  cases  to  be  made 
in  which  hemotrhage  was  a  contributive  rather  than  an 
essential  lesion,  and  in  the  direct  study  of  other  forms  of 
injury. 

The  exceptional  occurrence  of  delirium  is  probably  to 
be  attributed  to  the  cerebral  lesion,  which  was  well  marked 
in  each  instance. 

Much  importance  has  been  attributed  to  disturbance  of 
the  pupils  in  traumatic  hemorrhage,  and  a  lack  of  sym- 
metry was  observed  in  the  greater  part  of  the  cases  now 
subjected  to  examination.  It  was  unnoted  in  three  of 
those  which  were  fatal  and  in  three  of  those  which  were 
submitted  to  operation ;  the  pupils  were  normal  in  but  five 
out  of  the  remaining  thirty-three.  The  pupils  in  the  cases 
of  abnormity  afforded  almost  every  possible  combination 
of  dilatation  with  contraction.  In  seven  cases  both  pupils 
were  dilated,  the  hemorrhage  in  four  being  epidural,  in 
two  pio-arachnoid,  and  in  one  epidural  and  pio-arachnoid 
combined;  in  four  cases  both  pupils  were  contracted,  the 
hemorrhage  being  in  one  epidural,  in  one  pial,  and  in  two 
both  epidural  and  arachnoid ;  in  six  cases  the  pupil  was 
dilated  on  the  side  of  injury  and  contracted  on  the  oppo- 
site side,  while  in  two  cases  the  pupil  was  contracted  on 
the  side  of  injury  and  dilated  on  the  opposite  side,  the 


96  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

hemorrhage  in  each  being  epidural  and  derived  from  the 
middle  meningeal  artery;  in  three  cases  the  pupil  was 
dilated  on  the  side  of  injury  and  normal  on  the  opposite 
side,  the  hemorrhage  in  each  being  epidural;  in  three 
cases  the  pupil  was  normal  on  the  side  of  injury  and 
dilated  on  the  opposite  side,  the  hemorrhage  being  cortical 
in  two  and  epidural  in  one;  in  one  case  both  pupils  were 
primarily  contracted,  and  later  one  became  slightly  dilated 
on  the  side  of  an  epidural  and  of  a  pial  hemorrhage ;  and 
in  a  final  case  both  pupils  were  at  times  dilated,  and  at 
others  only  the  corresponding  pupil,  the  hemorrhage  being 
pial.  There  was  no  instance  of  contracted  pupil  on  either 
side  without  change  in  its  fellow.  In  the  three  cases  in 
which  both  pupils  remained  normal,  the  hemorrhage  was 
epidural  in  one,  pial  in  another,  and  cortical  in  the  third. 
The  hemorrhages  occurred  upon  every  part  of  the  cerebral 
and  cerebellar  surfaces,  vertex,  and  base. 

There  seems  to  be  no  change  in  the  pupils  which  is 
positively  characteristic.  In  two-thirds  of  the  cases  ana- 
lyzed, the  hemorrhage  was  wholly  or  in  part  epidural,  and 
in  two-thirds  of  these  again  one  pupil  or  both  was  dilated ; 
but  as  in  the  aggregate  all  sorts  of  pupillary  changes  re- 
sulted from  all  sorts  of  hemorrhages,  their  observation  can 
be  scarcely  more  than  confirmatory  of  an  opinion  justified 
by  the  collation  of  other  symptoms.  The  unilateral  dila- 
tation of  the  pupil  on  the  side  corresponding  to  an  epidural 
extravasation,  correctly  attributed  by  Mr.  Hutchinson  to 
pressure  upon  the  third  cranial  nerve,  is  the  only  pupillary 
condition  which  is  in  any  sense  diagnostic.  If  an  epidural 
hemorrhage  is  sufficiently  large,  and  occupies  the  anterior 
part  of  the  middle  fossa,  it  is  an  almost  positive  symptom ; 
but  in  any  other  form  or  situation  of  hemorrhage  there  is 


SYMPTOMATOLOGY.  9/ 

no  reason  for  its  occurrence,  and  even  in  large  epidural 
effusion  from  rupture  of  the  arteria  meningea  media  the 
corresponding  pupil  may  be  normal  or  contracted  and  dila- 
tation occur  upon  the  opposite  side.  The  pupillary  varia- 
tions, aside  from  the  dilatation  which  comes  from  direct 
pressure  upon  the  third  nerve,  are  to  be  referred  not  to 
hemorrhage  but  to  coincident  cerebral  injury.  The  fixity 
of  the  pupil  will  be  usually  proportionate  to  the  extremity 
of  its  contraction  or  dilatation,  and  will  indicate  the  extent 
or  severity  of  the  lesion  with  which  it  is  associated. 

The  temperature  which  attends  intracranial  hemor- 
rhage is  characteristic  when  considered  in  relation  to  sur- 
rounding conditions.  It  hardly  requires  an  examination 
of  cases  to  prove  that  the  direct  effect  of  a  loss  of  blood  is 
to  depress  all  the  vital  functions — to  diminish  temperature, 
as  it  relaxes  the  muscular  system  or  weakens  the  force  of 
the  circulation.  If  the  extravasation  is  rapid  or  profuse, 
it  is  an  essential  element  of  shock,  and  temperature  is  at 
once  reduced  below  the  normal  standard.  If  the  hemor- 
rhage is  not  too  great  to  permit  reaction,  the  temperature 
becomes  and  remains  normal.  The  coincidence  of  lesions 
characterized  by  an  elevation  of  temperature  may  counter- 
act the  effect  of  shock  and  there  is  no  reduction,  or  there 
may  be  even  an  increase  of  heat  at  the  beginning;  the 
secondary  temperature  will  then  be  elevated  in  proportion 
to  the  extent  of  these  coincident  lesions.  As  hemorrhage 
is  never  absolutely  independent  of  cerebral  injury,  if  the 
patient  survive  the  immediate  depression  of  shock  there 
will  always  be  some  subsequent  elevation  of  temperature. 
In  comparatively  uncomplicated  hemorrhage,  therefore,  the 
primary  temperature  should  be  normal  or  subnormal  as 
the  effusion  varies  in  amount  and  as  shock  is  more  or  less 

7 


98  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

pronounced;  and  later  should  be  only  moderately  in- 
creased. The  facts  derived  from  clinical  observation  are 
in  accord  with  these  preconceptions.  In  seven  of  the  ne- 
cropsic  cases  previously  selected  for  examination,  the  tem- 
perature was  unrecorded ;  in  thirteen  it  was  subnormal  on 
admission  to  the  hospital,  and  in  eight  it  was  from  99°  to 
99° -(-  ;  in  two  it  was  101°,  and  in  one  it  was  102°.  In 
the  three  cases  last  mentioned,  general  cerebral  contu- 
sion was  sufficiently  pronounced  to  account  for  the  special 
rise  in  temperature.  In  those  cases  in  which  it  subse- 
quently exceeded  101°,  eight  in  number,  there  was  in 
each  instance  some  severe  coexistent  lesion — general  con- 
tusion in  all,  which  in  several  w^as  excessive  and  in  two 
was  attended  by  laceration.  In  the  only  one  of  the 
eight  operative  cases  in  which  temperature  at  any  time 
attained  an  deviation  of  102°,  it  accompanied  the  for- 
mation of  a  fungus  cerebri.  In  these  thirty-nine  cases, 
best  fitted  for  observation  as  presenting  hemorrhage  in  as 
nearly  an  uncomplicated  or  distinctive  form  as  the  con- 
ditions of  intracranial  traumatism  permit,  the  character- 
istic temperature  would  thus  seem  to  range  from  99°  to 
101°,  after  reaction  from  shock. 

The  pulse  was  unnoted  in  five  cases.  It  was  normal  in 
four  cases,  in  two  of  which  hemorrhage  was  epidural,  cov- 
ering the  convex  surface  of  a  hemisphere,  and  in  two  was 
of  pial  or  cortical  origin,  occupying  the  inferior  occipital 
fossae.  In  ten  cases  in  which  the  pulse  was  slow,  the 
hemorrhage  in  each  was  epidural  and  the  patient  entirely 
unconscious.  In  the  remaining  cases  the  pulse  was  fre- 
quent and  the  hemorrhage  was  of  either  variety  and  vari- 
ously situated.  In  neither  the  fatal  nor  the  operative 
cases  was  there  any  further  definite  relation  discovered 


SYMPTOMATOLOGY.  99 

between  the  cliaracters  of  the  pulse  and  the  seat  or  nature 
of  the  hemorrhage,  nor  between  them  and  the  associated 
symptoms.  There  is  another  pulse  condition,  a  want  of 
symmetry  in  the  radial  pulsations  upon  the  two  sides  of 
the  body,  which  is  also  found  to  occur  in  connection  with 
other  intracranial  injuries,  the  consideration  of  which  may 
be  conveniently  deferred. 

The  respiration  was  sometimes  normal  at  the  first  obser- 
vation, or  even  until  the  end,  but  oftener  it  was  acceler- 
ated or  retarded.  It  is  generally  supposed  that  a  full, 
slow,  and  stertorous  respiration  is  characteristic  of  a  free 
intracranial  hemorrhage.  This  was  true  of  a  certain  pro- 
portion of  the  cases  which  have  been  cited,  but  not  of  a 
sufficient  number  to  establish  a  general  rule.  The  varia- 
tions from  such  a  standard  were  constant  and  apparently 
independent  of  the  form  or  location  of  the  hemorrhage. 
Thus  in  two  large  pial  effusions  over  the  vertex,  respiration 
was  in  each  primarily  unchanged,  and  later  became  in  one 
rapid  and  in  the  other  slow  and  stertorous.  In  two  large 
epidural  extravasations  in  the  same  situation,  it  was  in  one 
stertorous  and  of  nearly  normal  frequency,  and  in  the  other 
was  continuously  accelerated  without  other  change.  In  two 
other  epidural  cases  it  was  slow  throughout  their  course, 
but  without  stertor.  In  still  other  cases,  stertor  was  noted 
with  either  slow  or  rapid  respiration  when  hemorrhage  had 
occurred  into  the  anterior  basic  fossae  or  upon  the  surface 
and  in  the  vicinage  of  the  pons.  In  all  these  instances 
some  degree  of  general  contusion  existed,  but  no  localized 
complication.  In  general,  the  frequency  of  respiration 
was  oftener  increased  than  diminished.  None  of  the  re- 
covering operative  cases  presented  any  noticeable  devia- 
tions from  the  normal  standard.     There   is  one  form  of 


lOO  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

hemorrhage  in  which  the  respiratory  indication  is  positive: 
in  this,  the  effusion,  which  is  always  of  pial  or  cortical  ori- 
gin, encroaches  upon  or  covers  the  medulla,  and  respira- 
tion either  suddenly  ceases  or  is  briefly  continued,  with 
perhaps  not  more  than  two  to  four  inspirations  per  minute ; 
this  extreme  infrequency  of  respiratory  action  is  never  ob- 
served with  subsequent  recovery  of  the  patient.  A  num- 
ber of  cases  of  this  character  are  to  be  found  in  the  ap- 
pended series.  In  thirteen  such  cases  the  hemorrhage  more 
or  less  thickly  covered  the  pons  and  medulla,  in  three  of 
which  the  blood  was  still  fluid ;  in  seven  of  them  it  was  de- 
rived from  cortical  laceration,  and  in  six  from  meningeal 
contusion.  In  five  instances  death  was  sudden  and  the 
final  respiratory  acts  were  unnoted ;  and  in  two  others  record 
was  neglected.  The  peculiarities  in  respiration  which  they 
present  may  be  best  exhibited  in  tabular  form : 
No.  1-5.  No  record. — Death  sudden. 
No.  6-'j.  No  record. — Neglect. 
No.  8.   Respiration,  7  per  minute — only  one  record  made. 

Death  in  five  minutes. 
No.  9.   Respiration  normal  till  suddenly  reduced  to  13  and 
then  to  7  just  before  death  in  eight  and  one-half 
hours. 
No.  10.   Respiration  13   per  minute  on  admission,  reduced 

to  4  at  death  in  twenty  minutes. 
No.  II.  Respiration  14  per  minute  on  admission;  12  for 
one  and  one-half  hours ;  10  at  end  of  two  and  one- 
half  hours ;  8  at  end  of  three  hours ;  6  at  end  of 
four  and  one-half  hours;  4  at  end  of  five  hours; 
and  2  a  few  moments  later,  in  articulo  mortis. 
No.  12.  Respiration  2  per  minute  at  first  record  at  time  of 
death,  thirty  minutes  after  admission. 


SYMPTOMATOLOGY.  lOI 

No.  13.   Respiration   5  per  minute  from  first  observation 

immediately  after  injury  till  a  moment   before 

death  twenty  minutes  later,  when  it  was  reduced 

to  3. 

In  two  instances  radial  pulsation  continued  for  two  and 

three  minutes  after  respiration  had  ceased,  as  sometimes 

happens    after    mechanical    occlusion    of    the    larynx    or 

trachea. 

In  an  additional  case,  in  which  a  cortical  clot  was  found 
upon  the  pons  and  some  small  coagula  upon  one  side  of 
the  medulla,  the  respiration  on  admission  was  five  per 
minute  when  the  patient  was  quiet,  but  increased  to 
twenty  to  twenty-five  when  he  was  disturbed,  and  subse- 
quently ranged  from  thirty -six  to  forty-six  till  death.  It 
is  probable  that  the  small  coagula  observed  upon  the  me- 
dulla were  traces  of  a  larger  hemorrhage,  which  primarily 
encroached  upon  its  lateral  aspect  and  at  that  time  re- 
tarded the  respiratory  function. 

In  three  cases  the  hemorrhage  covered  the  medulla, 
with  little  or  no  implication  of  the  pons : 

1.  After  recovery  from  a  brief  period  of  unconscious- 
ness death  occurred  suddenly  twenty-five  minutes  later. 
Respiration  could  not  be  noted ;  the  hemorrhage  was 
pial. 

2.  Respiration,  30  per  minute  on  admission;  one  and 
one-quarter  hours  later  death  occurred  suddenly,  respira- 
tion having  dropped  to  4.  Cortical  hemorrhage  from  a 
laceration  of  the  cerebellum  covered  the  posterior  surface 
of  the  medulla;  the  fourth  ventricle  was  also  distended  b}'- 
a  clot. 

3.  Thirty-six  hours  after  admission  respiration  was 
suddenly  reduced  to  4  in  the  minute,  and  death  followed 


102  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

thirty  minutes  afterward.  A  cortical  hemorrhage  covered 
the  anterior  medullary  surface  and  extended  into  the 
spinal  canal. 

In  two  cases  a  pial  hemorrhage  which  reached  the 
pons  did  not  extend  to  the  medulla: 

1.  Respiration  on  admission,  21,  with  occurrence  soon 
afterward  of  a  sudden  attack  of  extreme  dyspnoea  and  cy- 
anosis, which  lasted  only  three  or  four  minutes,  and  was 
followed  by  numbness  of  both  arms.  There  was  no  fur- 
ther respiratory  disturbance.  Death  eighteen  hours 
later. 

2.  Respiration  on  admission,  21,  which  later  was 
increased  to  42  per  minute.  No  cyanosis  or  pulmonary 
oedema. 

Though  the  pons  and  medulla  were  both  involved  in 
the  great  majority  of  instances,  the  fact  that  diminished 
frequency  of  respiration  characterized  other  cases  in 
which  the  medulla  was  alone  affected,  and  was  not  ob- 
served in  others  in  which  the  extravasation  reached  the 
pons  without  extending  to  the  medulla,  clearly  demon- 
strates the  medullary  origin  of  this  symptom.  It  seems 
hardly  questionable  that  it  results  from  direct  compression 
of  the  respiratory  centre.  If  the  access  of  blood  to  the 
medullary  surface  is  sufficiently  sudden  and  profuse, 
whether  at  the  time  of  injury  or  at  some  later  period,  the 
cessation  of  respiration  may  be  without  warning  and  as  in- 
stantaneous as  in  direct  destruction  of  the  ganglion ;  if 
the  afflux  be  gradual  but  persistent,  its  retardation  may 
be  as  slowly  progressive  as  in  the  cited  case,  in  which  it 
could  be  watched  through  hours.  It  is  remotely  possible 
that  the  accumulated  blood,  while  still  fluid,  may  detach 
itself  and  the  incipient  paralysis  of  the  respiratory  function 


SYMPTOMATOLOGY.  IO3 

be  relieved,  as  is  suggested  by  the  history  and  post-mor- 
tem appearances  of  another  of  the  tabulated  cases. 

Certain  cases  in  which  respiration  was  equally  retarded, 
and  in  which  opportunity  for  necropsic  confirmation  was 
wanting,  have  not  been  described. 

Cyanosis  and  pulmonary  oedema,  which  occurred  in  but 
five  instances,  including  the  two  in  which  hemorrhage  did 
not  extend  beyond  the  pons,  are  independent  of  the  gan- 
glionic disturbance.  These  symptoms  in  this  relation  are 
to  be  ascribed  to  compression  of  the  intracranial  portion  of 
the  pneumogastric  nerve. 

Irregularities  of  respiratory  rhythm,  which  are  occa- 
sionally noted  in  cases  of  hemorrhage,  are  due  to  concom- 
itant cerebral  lesion. 

The  disturbance  or  abrogation  of  muscular  function 
was  an  occasional  symptom,  and  was  exhibited  in  accord- 
ance with  established  laws  of  cerebral  localization.  Paral- 
ysis occurred  in  three  of  the  fatal  cases  and  in  two  of  those 
which  recovered  after  operation ;  it  was  hemiplegic  in 
four  and  paraplegic  in  one.  Muscular  rigidity,  affecting 
one  side  or  both,  occurred  in  six  cases ;  and  general  con- 
vulsions in  three,  in  one  of  which  the  paroxysms  preceded 
injury;  simple  twitching  of  the  muscles  characterized 
three  others.  In  each  case  some  part  of  a  motor  area  was 
covered  by  the  hemorrhage,  which  was  variously  epidural, 
pial,  or  cortical,  and  acted  as  a  paralyzing  or  an  irritant  le- 
sion, according  to  its  extent  and  situation.  These  motor 
disturbances,  while  of  great  positive  diagnostic  import- 
ance, are  so  frequently  absent  that  they  have  no  corre- 
sponding negative  value.  In  a  single  case  in  which  there 
was  protrusion  of  both  eyes  as  well  as  dilatation  of  the  pu- 
pils, there  was  found  an  epidural  clot  in  the  right  inferior 


104  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

occipital  fossa,  and  a  thin  cortical  hemorrhage  which  cov- 
ered both  frontal  and  both  parietal  lobes  as  far  as  the  fis- 
sure of  Rolando. 

Psychical  disturbances  were  still  more  infrequent.  De- 
lirium occurred  in  several  instances;  in  one,  which  was 
primary,  the  hemorrhage,  as  disclosed  by  the  trephine, 
was  epidural  and  in  trivial  amount ;  in  the  other  and  fatal 
cases,  in  which  the  hemorrhage  was  pial  or  cortical  and  in 
larger  amount,  there  was  no  apparent  closer  connection 
between  the  symptom  and  the  lesion.  In  all,  a  general 
cerebral  contusion  was  evident,  and,  as  before  stated, 
probably  occasioned  the  mental  disorder.  Partial  anaes- 
thesia, irritability,  and  restlessness  were  observed  in  iso- 
lated cases. 

In  order  further  to  test  the  diagnostic  value  of  the 
symptoms  observed  in  this  limited  number  of  cases,  an 
equal  number  of  others  have  been  analyzed,  in  which, 
though  the  associated  lesions  were  more  severe,  the  hem- 
orrhage was  sufficiently  large,  absolutely  and  relatively,  to 
be  the  source  of  distinguishable  symptoms.  They  present 
some  points  of  difference  which  naturally  follow  from 
different  attendant  conditions.  In  the  larger  proportion 
of  both  necropsic  and  operative  cases,  in  which  hemor- 
rhage seemed  to  be  the  single  source  of  danger,  it  was  of 
epidural  origin.  In  this  group  of  cases,  in  which  the 
brain  and  its  membranes  are  more  seriously  involved,  it  is 
with  few  exceptions  essentially  pial  or  cortical.  When 
these  parts  are  the  seat  of  excessive  general  contusion 
without  laceration,  the  pial  vessels  are  the  ones  to  suffer 
rupture,  and  in  every  such  instance  the  hemorrhage  if 
subdural  was  of  this  character ;  in  two  it  chanced  to  be 
epidural.       When    the    brain    substance    is    superficially 


SYMPTOMATOLOGY.  I05 

wounded,  the  cortical  vessels  are  obviously  most  likely  to 
be  the  source  of  hemorrhage.  It  is  also  inevitable  that 
when  life  is  prolonged  the  symptoms  of  hemorrhage 
should  be  often  modified,  superseded,  or  complicated  by 
others  characteristic  of  the  additional  lesion. 

The  temperature  loses  its  diagnostic  importance.  It  is 
generally  higher  than  in  the  previous  instances  in  which 
hemorrhage  has  been  complicated.  In  ten  cases  it  ranged 
from  105°  to  107.8°,  and  in  twenty-six  it  exceeded  103°. 
In  the  cases  which  terminated  fatally  within  twenty-four 
hours,  which  was  the  usual  limit  of  life  when  approxi- 
mately uncomplicated  hemorrhage  proved  fatal,  the  tem- 
perature was  still  within  the  limit  of  101° +;  in  four, 
however,  in  which  death  occurred  within  even  less  than 
twelve  hours,  it  rose  to  102.2°,  103°,  106.8°,  and  107.8°. 

Consciousness  in  these  cases,  as  in  those  subjected  to 
operation,  was  less  uniformly  abolished  than  when  death 
seemed  to  result  directly  from  hemorrhage;  yet  in  far 
the  larger  number  its  loss  was  primary,  complete,  and 
permanent.  In  some  it  was  at  first  partial,  but  was  pro- 
gressive and  eventually  complete ;  in  others  primary  un- 
consciousness merged  in  delirium ;  in  a  few  instances  con- 
sciousness was  at  first  retained,  onlv  to  be  lost  at  a  later 
period.  In  general,  the  results  of  this  examination  are 
confirmatory  of  those  obtained  in  the  study  of  the  less 
complicated  cases. 

The  condition  of  the  pupils  was  less  diversified  than  in 
the  cases  previously  detailed.  It  was  normal  in  about  the 
same  proportion  of  those  in  which  record  Avas  made. 
There  was  much  more  frequent  dilatation  of  both  pupils; 
an  equal  number  in  which  both  were  contracted ;  and  con- 
sequently fewer  instances  in  which  the  two  presented  op- 


Io6  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

posite  conditions.  As  before,  there  was  no  case  in  which 
one  pupil  was  contracted  without  change  in  its  fellow. 
When  both  pupils  were  abnormal  the  hemorrhage  was 
usually  bilateral,  and  in  unilateral  dilatation  the  hemor- 
rhage was  usually  upon  the  corresponding  side;  but  in 
neither  case  was  the  rul6  invariable.  In  two  cases  with 
normal  pupils  the  hemorrhage,  which  was  large  in  each, 
was  epidural  in  one  and  pial  in  the  other,  and  in  both  was 
associated  with  important  lesion  of  the  brain  substance. 

The  pulse,  perhaps  under  the  influence  of  opposing 
forces,  was,  whenever  registered,  usually  normal.  It  was 
occasionally  slow  or  unduly  frequent,  and  often  exhibited 
that  want  of  symmetry  in  force  and  fulness  upon  the  two 
sides  of  the  body  which  has  been  mentioned  as  occurring 
in  different  forms  of  intracranial  injury. 

The  respiration  was  unnoted  in  one-third  of  the  cases, 
and  in  many  of  these  it  was  doubtless  unaffected,  since  in 
the  earlier  observations  normal  conditions  were  unrecord' 
ed.  If  moderate  allowance  be  made  for  such  omissions, 
the  proportion  of  mixed  cases  in  which  its  frequency  was 
from  1 8  to  24  to  the  minute,  and  in  which  it  was  without 
special  characteristics,  was  from  one-third  to  one-half; 
while  in  those  in  which  hemorrhage  was  more  nearly  an 
isolated  lesion  it  was  exceptionally  of  normal  character. 
The  remaining  cases  in  which  it  was  abnormally  slow  or 
frequent  were  necessarily  few. 

The  muscular  system  more  frequentl}-  in  this  class  of 
cases  afforded  symptomatic  indications.  In  each  instance 
in  which  an  irregular  excitation  of  functional  activity  was 
manifested  by  either  clonic  or  tetanic  contraction,  the 
hemorrhage  was  complicated  by  brain  laceration ;  in  those 
in  which  muscular  power  was  lost  or  held  in  abeyance,  the 


SYMPTOMATOLOGY.  10/ 

complicating  lesion  was  general  contusion.  Clonic  con- 
tractions were  relatively  frequent ;  general  convulsions  oc- 
curred in  six  of  the  mixed  cases.  General  muscular  rigid- 
ity was  noted  in  the  two  classes  with  more  nearly  equal 
frequency.  These  facts  are  suggestive  of  the  influence 
exerted  by  different  lesions.  • 

Since  in  the  group  of  cases  under  consideration  the 
hemorrhage  is  in  each  instance  associated  with  some  se- 
rious injury  of  the  iminediate  seat  of  sensory  and  intellec- 
tual function,  symptoms  which  depend  upon  disturbance 
rather  than  upon  simple  oppression  of  the  nerve  centres 
are  to  be  regarded  here  as  only  indirect.  Delirium,  irri- 
tability, or  restlessness,  when  of  immediate  occurrence 
and  when  the  effusion  is  moderate  in  amount,  may  be  con- 
sidered symptoms  of  hemorrhage,  but  only  in  the  sense 
that  a  pleuritic  pain  is  counted  a  symptom  of  pneumonia. 
It  is  unnecessary,  therefore,  when  direct  brain  injury  is  a 
recognized  factor,  to  investigate  such  conditions  while  en- 
gaged in  the  study  of  uncomplicated  hemorrhages. 

In  the  many  intracranial  injuries  in  which  hemorrhage 
is  relatively  inconsiderable,  its  indications  will  be  lost  in 
the  manifestations  of  graver  complications;  and  in  other, 
and  perhaps  recovering  cases,  in  which  it  is  absolutely  in- 
significant, it  may  be  even  devoid  of  symptoms. 

2.  Contusion. 

a.    General  Contusion  of  the  Brain. 

Notwithstanding  the  very  constant  occurrence  of  dif- 
fuse contusion  of  the  brain,  it  so  rarely  terminates  fatally 
when  uncomplicated  by  other  structural  changes  that  op- 
portunity for  observation  of  its   distinctive  symptoms  is 


I08  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

much  more  limited  than  in  hemorrhage.  There  are,  how^ 
ever,  eight  cases  of  the  appended  series  in  which  no  con- 
comitant lesion  existed,  or  in  which  if  present  it  was  so 
trivial  that  it  may  be  assumed  to  have  had  no  import- 
ance in  the  production  of  symptoms.  In  one  there  was 
absolutely  no  perceptible  change  beyond  the  general  con- 
tusion ;  in  two  there  were  also  limited  and  non-infective 
thromboses  of  dural  sinuses;  in  two  there  was  a  slight 
pial  hemorrhage;  in  another  there  was  a  single  small 
hemorrhage  into  an  optic  thalamus;  and  in  the  other  two 
there  was  in  each  a  trivial  cortical  laceration,  with  a  cor- 
respondingly unimportant  cortical  hemorrhage.  In  all 
there  was  a  more  or  less  intense  general  hypersemia,  which 
was  sometimes  more  strongly  pronounced  in  some  particu- 
lar region,  as  anteriorly,  posteriorly,  at  the  base,  or  in  one 
hemisphere,  than  elsewhere.  In  four  cases  the  pia  was 
notably  engaged ;  in  four  there  was  well-marked  or  even 
excessive  general  oedema ;  in  four,  thrombosis  of  the  mi- 
nute vessels,  which  generally  characterizes  contusion,  was 
a  distinct  feature.  The  last-mentioned  condition  is  to  be 
regarded  as  a  manifestation  of  contusion,  as  it  is  habitu- 
ally absent  in  the  hyperaemia  of  idiopathic  disease.  In 
those  cases  in  which  death  was  long  deferred,  the  absence 
of  inflammatory  processes  was  verified  by  microscopic 
examination  made  at  the  time  of  necropsy. 

The  analysis  of  symptoms  in  the  eight  cases  is  unsatis- 
factory. The  few  connecting  links  which  measurably 
held  together  the  cases  of  hemorrhage  have  no  corre- 
sponding representation.  There  was  no  uniformity  either 
in  the  occurrence  of  individual  symptoms  or  in  their 
course  and  termination.  In  the  single  one  which  was  ab- 
solutely uncomplicated,  there  was  no  loss  of  consciousness 


SYMPTOMATOLOGY.  IO9 

at  any  time  till  its  final  lapse  from  asthenia ;  in  all  the 
others  it  T\'as  primary,  and  in  three  ^'as  permanent. 
There  is  no  other  individual  symptom  which  occurred  in 
more  than  half  the  cases  cited.  The  pupils  were  dilated, 
contracted,  or  normal ;  the  pulse  and  respiration  were  va- 
riable. It  is  true  that  delirium  and  mental  irritability  or 
apathy,  combined  with  muscular  rigidity,  convulsions,  or 
some  degree  of  paralysis,  occurred  in  each  instance  save 
one,  and  in  that  one  a  profound  coma  from  the  beginning 
held  in  abeyance  all  mental  and  motor  functions ;  but  the 
time  of  their  appearance  and  the  method  of  their  combina- 
tion had  no  conformity  to  rule.  Headache,  persistent 
vomiting,  and  perforating  ulcer  of  the  cornea  were  iso- 
lated phenomena,  and  in  one  protracted  case  dementia 
preceded  death.  The  temperature  probably  afforded  the 
earliest  indication  of  the  intracranial  condition.  It  was 
never  subnormal  on  admission,  and  never  more  than  mod- 
erately elevated:  in  five  cases  it  was  from  99°  to  100°, 
and  in  two  it  was  101°  -^.  Its  subsequent  course  was  in 
general  progressive,  and  with  one  exception  attained  a 
high  degree  before  death  ensued.  Recessions  were  ob- 
served only  once  or  twice  in  two  cases,  which  were  consid- 
erably prolonged. 

It  is  not  difficult  to  comprehend  the  reasons  for  the  di- 
versity of  symptoms,  or  for  their  irregular  development, 
in  view  of  the  comprehensiveness  of  the  lesion  and  its 
different  degrees  of  intensity  in  different  regions.  The 
observation  of  the  fact  of  regional  variations  is  not  limited 
to  the  comparatively  few  necropsies  in  which  uncompli- 
cated general  contusion  has  been  found  to  exist,  but  is 
even  redundantly  confirmed  in  the  far  greater  number 
in  which   death  resulted  from  hemorrhage,  arachnitis,  or 


I  10  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

extensive  laceration.  It  is  not  unusual  in  case  of  a  contu- 
sion which  involves  the  entire  brain  to  find  that  its  struc- 
tural evidences  are  emphasized  in  one  hemisphere,  or  in 
certain  lobes,  or  in  certain  regions,  it  may  be  in  the  cor- 
tex, the  basal  ganglia,  or  elsewhere.  It  is  not  more  un- 
usual to  find  in  a  largely  diffused  contusion  that  some 
part,  as  the  cortex,  one  hemisphere,  or  the  cerebellum, 
has  practically  escaped.  All  the  characteristic  structural 
alterations  are  alike  subject  to  localization.  The  post- 
mortem inspections  of  the  brain  have  demonstrated  also 
the  instability  of  the  parenchymatous  serous  exudation ; 
this  not  only  gravitates  to  dependent  parts,  but  can  often 
be  freely  expressed  by  hand  after  section  has  been  made. 
The  dropsical  effusion  moves  through  the  brain  substance 
with  the  same  certainty,  if  not  with  the  same  celerity, 
that  it  does  through  subcutaneous  cellular  tissue.  There 
is  no  more  reason  to  question  the  fluctuation  during  life  in 
the  amount  or  position  of  serous  transudation,  or  in  the 
intensity  of  hyperaemia  originally  established  by  violence, 
than  there  is  to  doubt  their  often  progressive  increase  or 
diminution.  The  punctate  hemorrhages  into  the  brain 
substance  are,  of  course,  not  subject  to  change,  and  are 
less  influential  in  the  modification  of  symptoms  than  the 
conditions  previously  described. 

These  considerations  seem  sufficient  to  account  for  the 
wide  variations  noted  in  symptomatology.  It  is  unneces- 
sary to  review  the  cases  which  illustrate  the  dependence 
of  symptoms  of  cortical  irritation  upon  cortical  contusion 
of  the  vertex,  or  of  pressure  symptoms  upon  excessive 
general  subcortical  hyperaemia  and  oedema,  or  of  various 
other  combinations  of  symptoms  with  structural  changes. 
It  is  quite  possible  that  wider  observation  may  further  illu- 


SYMPTOMATOLOGY.  Ill 

mine  the  invasion  and  march  of  symptoms,  but,  as  these 
must  continue  to  depend  upon  unstable  conditions,  they 
are  not  likely  even  then  to  become  fixed  elements  in  diag- 
nosis. 

Some  further  knowledge  of  the  symptoms  which  indi- 
cate the  existence  of  this  form  of  cerebral  injury  may  be 
gained  from  the  observation  of  the  very  simple  cases  in 
which  recovery  follows  without  a  suspicion  of  danger  be- 
ing incurred,  and  also  from  the  analysis  of  those  compli- 
cated fatal  cases  in  which  the  relative  value  of  different 
lesions  can  be  estimated  and  their  symptoms  studied  to 
some  extent  by  the  process  of  exclusion.  The  condition 
of  contusion  can  be  justifiably  assumed  in  the  former  class 
from  the  absence  of  known  indications  of  the  other  intra- 
cranial lesions,  and  in  certain  instances  from  the  occur- 
rence of  similar  cerebral  symptoms  with  diffuse  structural 
change  when  death  results  from  coincident  injury  of  the 
trunk  or  extremities.  In  these  relatively  unimportant 
cases  there  is  invariably  some  loss  of  consciousness  or 
some  mental  impairment.  In  those  which  are  deemed 
too  trivial  to  require  medical  attention,  a  momentary  un- 
consciousness, partial  or  complete,  or  some  vertigo  or 
mental  confusion,  with  a  sense  of  bodily  Aveakness,  and 
possibly  a  later  headache,  comprise  the  available  history. 
In  cases  of  somewhat  greater  severity  which  are  admitted 
to  hospital  additional  symptoms  are  usually  present. 
Consciousness,  which  may  have  been  lost  for  a  variable 
period,  has  been  usually  regained.  Twenty-five  cases  of 
this  nature,  many  of  which  involved  simple  fissure  of  the 
vertex,  but  without  other  cranial  or  more  distant  complica- 
tion, and  without  coincident  intracranial  lesion  so  far  as 
could  be   determined,  were  subjected  to  comparative  ex- 


112  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

amination.  The  temperature  on  admission  was  habitually 
99°  -\-  ;  in  the  exceptional  instances  it  was  practically  nor- 
mal or  else  subnormal  from  shock ;  its  later  extreme  ele- 
vation was  ioi°.  The  axillary  temperature  was  not  or- 
dinarily observed,  but  in  one  typical  case  of  contusion  it 
was  always  higher  upon  the  left  than  upon  the  right  side, 
usually  0.6°,  with  a  maximum  of  1.8°,  in  a  course  of  four 
daily  observations  extending  over  seventeen  days.  The 
pulse  on  admission  was  usually  moderately  increased  in 
frequency,  ranging  from  90  to  116,  but  in  a  smaller  pro- 
portion of  cases  was  slightly  below  the  normal  standard ; 
its  later  variations  were  within  the  same  limits.  The  ra- 
dial pulsations  at  the  two  wrists  were  sometimes  unsym- 
metrical.  The  respiration  was  almost  uniformly  from  18 
to  26;  in  three  instances  on  admission  it  was  from  14  to 
16.  In  one  exceptional  and  inexplicable  case,  wnth  a  tem- 
perature of  99°  on  admission  to  the  hospital,  the  pulse 
was  170  and  the  respiration  40.  The  patient,  a  child,  was 
removed  from  observation  on  the  third  day,  and  was  then 
in  a  favorable  condition ;  it  is  possible  the  diagnosis  was 
not  thoroughly  established.  The  most  prominent  general 
symptoms  were  stupor,  somnolence,  headache,  vertigo,  ir- 
ritability, and  restlessness,  which  were  never  collectively 
manifested  in  a  single  case.  Unconsciousness,  or  a  dazed 
mental  condition,  sometimes  persisted  after  admission, 
and  delirium  occasionally  occurred.  Muscular  rigidity  or 
convulsions  were  exceptionally  noted.  The  pupils  were 
usually  normal,  but  when  changed  were  in  four  cases  sym- 
metrically dilated,  and  in  two  were  contracted,  in  one  of 
which  they  were  subsequently  irregularly  dilated,  and  at 
times  normal.  It  often  happened  that  not  more  than  one 
or  two  of  these  symptoms  were  observed,  and  sometimes 


SYMPTOMATOLOGY.  II3 

after  the  primary  and  transient  unconsciotisness  there  was 
absolutely  no  indication  of  cerebral  injury  aside  from  the 
rise  in  temperature. 

If  the  cerebral  contusion  is  of  maximum  intensity  and 
extent,  some  hemorrhage  or  laceration  is  almost  inevita- 
ble. Ten  cases  of  this  character  have  been  analyzed,  in 
which  large  pial  or  epidural  hemorrhages  have  coexisted 
with  excessive  or  moderate  hypersemia  and  oedema,  or 
with  hyperasmia  and  punctate  extravasations.  They  have 
been  selected  in  preference  to  others  in  which  lacerations 
existed,  as  likely  to  afford  a  clearer  differentiation  of 
symptoms.  The  loss  of  consciousness  was  primary  in  all, 
and  in  three  in  which  it  was  permanent  and  profound 
there  was  no  great  accumulation  of  extravasated  blood. 
In  the  larger  number  of  cases  in  which  an  interval  of  con- 
sciousness intervened  before  its  final  loss,  hemorrhage  Avas 
more  profuse ;  in  some  the  relapse  was  sudden ;  and  in 
others,  in  which  life  was  more  prolonged,  it  came  at  the 
end  of  a  period  of  progressively  increasing  stupor.  The 
initial  temperature  was  often  subnormal  from  shock,  and 
otherwise  was  not  higher  than  in  the  simpler  cases  of  con- 
tusion or  hemorrhage.  If  the  patient  survived  the  imme- 
diate effects  of  injury,  its  elevation  was  marked,  and  in 
these  few  instances  its  final  record  was  from  104.2°  to 
106.4°.  The  pulse  and  respiration  increased  in  fre- 
quency with  the  rise  in  temperature.  The  bilateral  radial 
pulsations,  as  in  the  previous  series  of  observations,  were 
not  always  symmetrical,  and  the  respiration  at  the  ap- 
proach of  death  sometimes  assumed  the  Cheyne-Stokes 
character,  which  is  not  observed  in  hemorrhages  or  in  the 
simpler  forms  of  contusion.  The  pupils  were  normal  in 
six  of  the  ten  cases ;  in  two  they  were  dilated,  in  one  of 


114  IN'JURIES    OF   THE    BRAIN    AND    MEMBRANES. 

which  an  epidural,  and  in  the  other  a  large  pial,  hemor- 
rhage occupied  one  of  the  middle  fossae;  and  in  two  they 
were  contracted,  in  one  of  which  a  pial  hemorrhage,  and 
in  the  other  pial  and  epidural  hemorrhages,  covered  the 
left  hemisphere.  In  both  cases  in  which  the  pupils  were 
contracted  there  was  also  loss  of  urinary  and  fsecal  control, 
and  in  both  the  brain  substance  was  oedematous.  Psychic 
disturbances  were  infrequently  manifested,  even  when 
more  or  less  perfect  consciousness  was  maintained  for 
some  time  in  the  progress  of  the  case;  delirium,  irritabil- 
ity, and  restlessness  were  symptoms  in  but  two  instances. 
Disorders  of  the  motor  function  were  present  in  a  larger 
proportion  of  cases,  and  included  rigidity,  convulsive 
movements,  and  full  convulsions.  The  two  cases  in  which 
general  convulsions  occurred  involved  in  each  a  large  pial 
hemorrhage  as  well  as  a  diffused  contusion ;  but  both  were 
susceptible  of  more  direct  explanation.  In  the  first,  in 
which  convulsions  were  confined  to  the  fifth  day  after  in- 
jur}', there  was  a  limited  contusion  of  a  temporal  lobe ;  in 
the  second,  in  which  the  paroxysms  were  almost  constant 
from  the  third  hour  after  injury  till  death  nine  hours 
later,  the  dura  was  intensely  congested.  The  relation  of 
lesion  of  the  temporo-frontal  region  of  the  brain  to  such 
disordered  muscular  action  will  be  shown  in  connection 
with  the  subject  of  cerebral  laceration.  The  result  of  ir- 
ritation of  the  dural  nerves  in  the  production  of  intense 
pain  and  of  convulsive  seizures  is  well  known. 

b.   Limited  Co7itiision  of  the  Brain. 

The  distinctly  limited  form  of  contusion,  as  distin- 
guished from  laceration,  demands  but  brief  consideration. 
In  the  occasional  instances  in  which  it  occurs  in  scattered 


SYMPTOMATOLOGY.  II5 

areas  through  the  centriim  ovale,  it  can  afford  no  indica- 
tions separable  from  those  of  a  modified  general  lesion. 
In  its  more  usual  form,  in  which  it  is  confined  to  the  cor- 
tex, it  differs  from  laceration  only  in  the  extent  of  local 
injury  to  tissue ;  and  the  character  of  the  symptoms  will 
not  be  farther  influenced  by  the  fact  that  the  injury  is  a 
bruise  rather  than  a  wound.  It  is  rarely  a  fatal  lesion, 
and  its  existence  is  likely  to  be  marked  by  the  coexistence 
of  others  of  greater  magnitude  or  severity.  It  has  been 
noted  in  but  sixteen  of  the  present  series  of  necropsic 
examinations,  and  in  none  of  these  had  it  appreciably 
contributed  to  the  fatal  result,  and  in  but  two  had  it 
occasioned  recognizable  symptoms.  In  the  exceptional 
instances  there  had  been  no  reason  during  life  to  suppose 
that  there  was  a  limited  contusion  rather  than  a  laceration. 

3.  Laceration  of  the  Brain. 

Cerebral  laceration  is  always  attended  by  some  degree 
of  general  contusion ;  in  like  manner  a  resultant  cortical 
or  intracerebral  hemorrhage  proportionate  to  the  extent  of 
local  injury,  and  often  sufficiently  large  to  have  an  intrin- 
sic value  in  the  development  of  symptoms,  is  almost  cer- 
tain to  exist  as  a  complicating  condition.  It  is  probable, 
however,  when  post-mortem  indications  of  general  injury 
are  not  pronounced,  and  laceration  is  extensive  with  not 
more  than  moderate  cortical  hemorrhage,  that  the  signifi- 
cant symptoms  have  been  derived  from  the  local  destruc- 
tion of  tissue.  In  the  series  of  cases  appended,  out  of  the 
larger  number  in  which  laceration  was  a  condition,  there 
were  fourteen  or  more  of  this  character.  They  com- 
prise   cortical    and    subcortical    injuries    variously    situ- 


Il6  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

ated  upon  and  beneath  the  several  surfaces  of  the 
brain,  and  involve  both  localizing  and  non-localizing  cere- 
bral areas.  As  the  location  not  less  than  the  character  of 
this  lesion  is  matter  of  concern,  these  instances  are  evi- 
dently too  few  for  generalization.  Comparable  cases,  so 
far  as  extent  of  local  injury  is  concerned,  may  be  wholly 
unlike  in  their  manifestations,  as  their  situation  may 
chance  to  trench  upon  different  cerebral  centres  of  control. 
Methods  of  comparison  and  analysis  which  are  fairly  ade- 
quate to  a  determination  of  the  significance  of  symptoms 
in  the  different  diffused  lesions,  even  when  applied  to  a  re- 
stricted number  of  cases,  fail  when  this  additional  factor  has 
to  be  considered.  The  series  of  fourteen  cases  of  relatively 
simple  laceration  is  too  much  attenuated  after  topographi- 
cal subdivision  to  afford  a  sufficient  basis  for  deduction. 

The  indication  of  temperature  must  be  excepted  from 
this  general  statement,  since  it  seemed  to  be  independent 
of  the  region  affected.  In  two  instances  temperature  was 
not  recorded ;  its  course  and  elevation  in  the  others  may 
be  conveniently  shown  in  tabular  form : 

Case  VI. — 103°  on  admission;  102°  five  hours  later, 
and  then  progressive  rise  to  106.2°  at  death  at  end  of 
twenty-four  hours. 

Case  XX. — 101°  on  admission;  104.8°  forty-eight 
hours  later  and  for  seventy-eight  hours  ensuing;  101°-)- 
to  i02°-|-  for  next  forty-eight  hours,  and  progessive  rise 
to  i07°-|-.     Death  in  seven  days  seven  hours. 

Case  XXI. — 104.8°  to  106°  from  first  record  to  death 
at  end  of  twenty-six  hours. 

Case  CLXI. — 98.6°  on  admission;  in  twenty-four 
hours,  102.6°;  in  thirty  hours,  103°;  and  in  thirty-two 
hours,  just  before  death,  104°.  One  hour  post  mortem  it 
had  risen  to  104.6°. 


SYMPTOMATOLOGY.  II7 

Case  CLXXII. — 98.6°  one  hour  after  admission; 
104.6°  in  seven  hours;  and  105.4°  in  fifteen  hours. 

Case  LXXXVIII. — 105°  before  death  fourteen  hours 
after  admission. 

Case  XCIV. — 97.6°  on  admission;  101.7°  in  nine 
hours;   102.8°  in  twelve  hours;  and  103°  in  fifteen  hours. 

Case  XCVII. — 98°  on  admission;  103.2°  in  six  hours; 
thirty  minutes  post  mortem,  103.4°. 

Case  CLXIV. — 96°  on  admission,  and  104.8°  in  one 
and  one-half  hours. 

Case  XCIX. — 98.4°  on  admission;  in  three  hours, 
103.2°;  in  six  hours,  106.2°;  and  in  nine  hours,  109.2°. 

Case  CIII. — 97.6°  on  admission;  in  four  hours, 
103.4°;  in  eight  hours,  100°;  in  eleven  hours,  104.2°;  in 
seventeen  hours,  105.4°;  and  in  eighteen  hours,  109°. 

Case  CVII. — 97.6°  on  admission;  in  three  hours, 
99.6°;  in  six  hours,  102°;  in  twelve  hours,  104°;  and  in 
twenty-four  hours,  105.2°. 

The  final  record  in  each  instance  immediately  pre- 
ceded death ;  the  post-mortem  observation  was  frequently 
if  not  usually  neglected.  It  is  to  be  understood  that  some 
diffuse  injury  always  existed,  but  in  an  exception- 
ally moderate  degree,  and  was  least  in  those  cases  in 
which  the  temperature  attained  the  highest  elevation. 
The  remarkable  primary  rise  in  temperature  which  often 
followed  recovery  from  shock,  and  its  rapid  and  progres- 
sive increase,  sometimes  continued  even  after  death,  and 
in  general  without  recession  when  the  fatal  issue  was  not 
long  delayed,  are  in  striking  contrast  to  what  has  been 
observed  in  simple  hemorrhages  and  contusions. 

The  symptoms  which  attend  laceration  are  better  stud- 
ied in  a  review  of  the  far  larger  number  of  cases  in  which 
limited  destructive  lesions  are  complicated  by  other  ana- 
tomical changes,  perhaps  equally  important.     It  will  then 


Il8  IN'JURIES   OF   THE    BRAIN   AND    MEMBRANES. 

be  necessary  to  exclude  those  symptoms  which  have  been 
found  to  be  referable  to  the  complicating  conditions  as 
they  have  occurred  elsewhere  in  comparative  isolation. 

The  high  temperatures  which  characterized  simple  lac- 
erations were  maintained  in  the  presence  of  complications. 
In  the  sixty-five  complicated  cases  which  were  analyzed, 
the  initial  observation  was  made  immediately  upon  admis- 
sion, but  was  not  recorded  as  primary  if  some  hours  or 
days  had  elapsed  after  the  reception  of  the  injury;  the 
ultimate  observation  was  denominated  final  only  when 
made  nearly  or  quite  in  articulo  mortis.  Rectal  tempera- 
tures only  were  noted.  The  cases  of  this  series,  which 
are  so  numerous  as  to  be  more  than  representative,  have 
been  selected  after  the  exclusion  of  those  which  have 
served  to  illustrate  the  relatively  uncomplicated  hemor- 
rhages, contusions,  and  lacerations,  and  in  which  no  in- 
flammatory sequela  was  discovered. 

The  primary  temperature  was  unnoted  in  four  cases  in 
which  admission  to  the  hospital  was  deferred,  was  normal 
in  two,  and  was  subnormal  in  fifteen ;  in  the  remaining 
forty-two  cases  it  was  from  99°  to  100°  inclusive  in  sixteen, 
ioo°-|-  in  eight,  ioi°-t-  in  eleven,  i02°-[-  in  six,  103.6°  in 
one,  and  io6°-io6.6°  in  two. 

The  final  temperature  was  109°  in  one  case,  108°-}-  in 
four  cases,  i07°-io7°-]-  in  thirteen,  io6°-io6°-|-  in  seven- 
teen, i05°-i05°-l-  in  eleven,  104.6°  in  two,  i03°-i03°-f-  in 
four,  i02°-i02°-|-  in  three,  101°  in  one  case,  and  100°  in 
another.  In  a  few  instances  these  final  observations  indi- 
dicated  recessions. 

In  fifty  cases  in  which  the  intermediate  temperatures 
were  recorded,  they  were  in  twenty-eight  without  reces- 
sion from  the  beginning  to  the  end,  and  in  several  others 


SYMPTOMATOLOGY.  II9 

with  no  more  than  a  single  interruption,  which  was  -unim- 
portant in  degree.  The  progressive  elevation  of  tempera- 
ture from  the  time  of  admission,  immediately  after  the  oc- 
currence of  injury,  was  often  exceedingly  rapid,  as  from 
94.2°  to  105.4°  in  nine  hours,  from  98°  to  106.6°  in  nine 
and  one-half  hours,  from  97.6°  to  107°  in  fifteen  hours, 
from  97.2°  to  105.2°  in  nineteen  hours,  and  from  102.6°  to 
106°  in  five  hours.  An  approximately  rapid  but  less  re- 
markable rise  in  temperature  not  infrequently  marked  the 
last  hours  of  life.  In  one  instance  the  primary  progres- 
sive elevation  was  followed  by  a  depression  to  97°+, 
which  persisted  nearly  a  week  before  the  advance  of  tem- 
perature was  resumed. 

These  extreme  elevations  of  temperature  have  been 
often  coincident  with  lesions  which  have  involved  what 
have  been  described  as  thermogenetic  centres,  and  rather 
noticeably  that  part  situated  near  the  antero-inferior 
aspect  of  the  corpus  striatum.  It  is  also  true,  however, 
that  laceration  of  any  portion  of  the  brain  is  followed  by  a 
high  temperature;  and  that  the  regions  in  which  these 
supposed  centres  are  situated  happen  to  be  most  subject  to 
injury.  It  is  therefore  questionable  how  far  the  study  of 
traumatism  has  confirmed  in  this  regard  the  results  of  cer- 
tain physiological  investigations.  The  highest  tempera- 
tures recorded,  and  those  in  which  progressive  increase  has 
been  most  rapid,  have  not  been  confined  to  lacerations  in- 
volving any  special  regions  of  the  brain.  They  have  indi- 
cated the  extent  or  severity  rather  than  the  situation  of 
the  injury,  and  have  included  lesions  of  the  frontal,  tem- 
poral, parietal,  and  occipital  lobes.  If  the  laceration  has 
not  been  large,  the  general  hypersemia  and  oedema  have 
been  excessive.     It  would  seem  probable  from  clinical  ob- 


120  INJURIES    OF    THE    BRAIN   AND    MEMBRANES. 

servation  that  the  high  temperatures  which  attend  cere- 
bral lacerations  and  contusions  depend  upon  general  nu- 
tritive changes,  and  not  upon  specific  lesion  of  the  nerve 
centres.  This  view  is  sustained  by  the  history  of  cases  in 
which  no  limited  lesion  existed.  In  one  of  these,  in 
which  the  rise  in  temperature  was  phenomenal,  there  was 
a  large  epidural  hemorrhage,  compressing  the  brain,  and  a 
moderate  general  hyperaemia  with  an  excessive  oedema, 
which  equally  involved  all  parts  of  the  viscus,  but  no  lo- 
calized injury.  The  patient  was  admitted  in  profound 
shock  and  died  one  and  one-half  hours  later.  The  temper- 
ature was  98.6°  at  the  time  of  death  and  immediately  af- 
terward; in  thirty  minutes  it  had  risen  to  109°—,  a  post- 
mortem elevation  of  10.4°.  There  can  be  no  doubt  that 
the  presumed  heat  centres  were  exempt  from  injury,  ex- 
cept as  they  suffered  contusion  in  common  with  all  the  rest 
of  the  brain  substance. 

In  cases  of  recovery  the  reduction  of  temperature  from 
99° -|-  was  often  very  slow,  and  sometimes  occupied  many 
weeks. 

It  is  still  impossible  to  estimate  the  undetermined  im- 
portance of  bilateral  variations  in  axillary  temperatures. 
The  observations  which  have  been  made  in  connection 
with  the  appended  series  of  cases  have  afforded  uncertain 
results,  which  have  been  often  apparently  inconsistent 
with  each  other,  even  in  the  same  case.  Temperature  is 
sometimes  uniform  upon  the  two  sides  of  the  body,  but  is 
very  often  higher  upon  one  than  the  other,  which  is  not 
always  the  same  with  reference  to  the  side  of  the  head  in 
which  the  lesion  is  situated.  The  differences  have  ranged 
from  0.2°  to,  in  one  instance,  nearly  3°,  and  have  been 
noted  in  repeated  observations  made  daily  for  more  than 


SYMPTOMATOLOGY.  12  1 

two  weeks.  It  may  be  said,  with  some  reserve,  that  when 
a  difference  exists  the  temperature  is  rather  more  fre- 
quently 0.2°  higher  upon  the  side  opposite  than  upon  that 
corresponding  to  the  seat  of  cerebral  injury. 

In  a  considerable  number  of  cases  the  final  rise  in  tem- 
perature was  continuous  for  a  certain  time  after  death. 
In  at  least  fifty  per  cent,  of  observations  made  after  the 
lapse  of  thirty  or  sixty  minutes,  the  post-mortem  increase 
was  from  0.2°  to  2°,  and  was  exceptionally  very  much 
greater;  while  in  the  remainder  the  temperature  had  fall- 
en or  was  unchanged.  The  practical  difficulties  which 
prevent  the  collection  of  these  data  in  all  of  a  great  num- 
ber of  cases,  as  in  the  notation  of  axillary  variations,  are 
readily  understood.  The  lesions  associated  with  the  post- 
mortem calescence  comprehend  all  those  which  have 
been  described.  The  one  which  was  most  nearly  constant 
was  laceration,  and  even  this  was  sometimes  dispropor- 
tionate to  the  severity  of  a  general  hyperaemia  or  to  the 
amount  of  a  cortical  hemorrhage  by  which  it  was  attended. 
In  the  remarkable  case  in  the  appended  series,  to  which  at- 
tention was  called  in  a  preceding  paragraph  and  in  which  the 
temperature  immediately  after  death  was  98.6°,  and  within 
thirty  minutes  rose  to  109°,  there  was  no  laceration;  a 
large  epidural  clot  compressed  the  left  parietal  and  tem- 
poral lobes,  and  the  brain  substance  was  everywhere  h)-- 
persemic  and  excessively  cedematous.  There  would  seem 
to  be  little  doubt  that,  at  least  in  this  instance,  the  gener- 
ation of  heat  must  have  been  due  to  post-mortem  general 
nutritive  changes  rather  than  to  continued  activity  of  spe- 
cial thermogenetic  centres.  It  has  not  been  in  general 
practicable  to  trace  any  connection  between  this  phenome- 
non and  the  region  of  the  brain  affected,  and  it  is  not  de- 


122  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

pendent  therefore  upon  injury  of  so-called  heat  centres. 
It  must  be  accepted  simply  as  a  continuation  of  a  thermo- 
genetic  process,  however  excited,  or  as  the  result  of  defi- 
cient thermolysis,  however  occasioned. 

The  pulse  and  respiration,  when  laceration  was  the  es- 
sential factor  in  the  production  of  symptoms,  were  not  far 
removed  from  the  normal  standard.  If  hemorrhage  co- 
incidently  compressed  the  medulla,  respiration  was  even 
fatally  retarded ;  or  if  general  shock  was  intense,  or  arach- 
nitis at  once  supervened  upon  meningeal  contusion,  or 
if  various  special  conditions  existed,  both  pulse  and  res- 
piration, or  either  one,  might  be  greatly  increased  in  fre- 
quency; but  these  cases  were  exceptional.  The  contrast 
habitually  presented  by  a  practically  normal  and  unaccel- 
erated  pulse  and  respiration,  with  general  symptoms  of 
perhaps  great  severity,  seems  scarcely  less  remarkable 
than  the  exaggerated  temperatures  which  have  been  the 
occasion  of  surprise  in  the  same  series  of  cases.  In  the 
great  majority  of  instances  of  serious  intracranial  injury, 
whether  fatal  or  not,  the  pulse  has  not  exceeded  90,  or  the 
respiration  26,  upon  early  examination.  The  pulse  when 
abnormal  has  oftener  than  otherwise  inclined  to  fulness 
and  slowness;  and,  in  the  absence  of  statistical  data,  a 
moderate  diminution  of  frequency  would  seem  characteris- 
tic. The  respiration,  on  the  contrary,  when  disturbed 
has  been  usually  hastened,  even  though  the  circulation 
has  been  retarded. 

The  want  of  symmetry  in  radial  pulsation  upon  oppo- 
site sides  of  the  body,  which  has  been  noted  in  connection 
with  other  intracranial  lesions,  is  also  a  symptom  in  cases- 
of  cerebral  laceration.  This  condition  was  first  recog- 
nized in  the  prosecution  of  the  present  work  in  May,  1893, 


SYMPTOMATOLOGY.  I23 

and  since  then  has  been  found  to  exist  in  from  thirty  to 
forty  of  the  appended  cases.  It  is  most  frequently  a  pri- 
mary aberration,  but  may  not  occur  until  a  later  period 
in  the  progress  of  the  case.  It  is  sometimes  evanescent, 
disappearing  in  a  few  hours,  and  again  extends  over  a 
number  of  days.  The  bilateral  variation  attaches  to  the 
strength  and  fulness  of  the  arterial  pulse,  Avhich  is  in  all 
other  respects  symmetrical.  In  one  instance  the  fuller 
pulse  was  the  more  compressible ;  in  all  others  it  Avas  also 
the  stronger.  The  original  characteristics  of  each  radial 
pulse  Avere  ordinarily  retained  as  long  as  a  difference  ex- 
isted, but  occasionally  they  were  interchanged.  In  some 
of  these  instances  the  fulness  and  strength  of  pulsation 
upon  one  side  were  in  startling  contrast  to  its  weakness 
and  tenuity  upon  the  opposite ;  in  others  the  apparent 
difference  was  slight,  and,  to  avoid  the  possibility  of  er- 
ror, was  excluded  from  record.  In  each  case  in  which  it 
was  accepted  as  a  symptom  it  Avas  confirmed  by  two  or 
more  observers,  and  if  not  indisputable  was  rejected. 
Twenty-one  cases  in  which  it  was  observed  terminated 
fatally,  of  which  seventeen  were  subjected  to  necropsy. 
In  the  recovering  as  well  as  in  the  fatal  cases  which  failed 
of  post-mortem  inspection,  the  nature  of  the  lesions  was 
sufficiently  evident  from  the  general  indications.  The 
necropsies  disclosed  all  forms  of  hemorrhage,  epidural, 
cortical  and  pial,  variously  situated;  lacerations,  more  es- 
pecially of  the  frontal  and  temporal,  but  also  of  the  parie- 
tal lobes,  and  of  each  of  the  basal  ganglia;  and  almost 
invariably  some  degree  of  general  contusion,  which  was 
sometimes  the  essential  lesion.  There  were  hemorrhages 
without  laceraton,  and  limited  contusions  without  hemor- 
rhage.    The  inferential   lesions,  those  not  demonstrable 


124  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

by  direct  inspection,  were  somewhat  less  diversified 
They  included  five  cases  of  depressed  fracture  of  the  ver- 
tex, with  epidural  hemorrhage  and  frontal  laceration  in 
one,  and  moderate  general  contusion  in  four;  nine  cases 
of  fractured  base,  with  probable  hemorrhage  in  all,  and 
with  laceration  or  general  contusion  in  all  but  one;  and 
three  cases  of  intracranial  injury  without  fracture.  The 
pulse  was  fuller  and  stronger  upon  the  side  corresponding 
to  the  seat  of  injury  in  nine  cases,  and  upon  the  side  op- 
posite in  thirteen ;  in  three  this  relation  was  unknown,  in 
one  instance  from  imperfect  clinical  record,  and  in  two 
others  from  the  existence  of  distinct  lesions  upon  both 
sides  of  the  brain.  In  several  of  these  cases  a  diffused 
contusion  was  well  marked  or  even  excessive. 

It  would  seem  impossible,  therefore,  to  infer  the  char- 
acter or  location  of  lesions  from  this  symptom  alone;  it  is 
equally  so  from  any  correlation  which  exists  between  it 
and  others  by  which  it  has  been  accompanied.  The  first 
few  cases  seemed  to  suggest  a  relation  to  the  pupillary 
condition,  which  larger  experience  has  shown  to  be  falla- 
cious. The  pupils  are  dilated  in  a  considerable  number  of 
cases,  normal  in  an  almost  equal  number,  and  contracted 
or  asymmetrical  in  others. 

An  abnormal  state  of  the  pupils  is  of  no  greater  import- 
ance in  laceration  than  in  other  encephalic  lesions.  The 
forms  and  combinations  of  pupillary  variation  have  been 
so  numerous,  and  the  instances  in  which  no  change  has 
taken  place  have  been  so  frequent,  that  no  inferences  of 
practical  value  can  be  derived  either  from  their  continued 
normal  condition  or  from  any  changes  which  they  may 
present.  In  the  cases  cited  in  illustration  of  the  symptoms 
of  comparatively  simple  lacerations,  the  pupils  were  un- 


SYMPTOMATOLOGY.  12  5 

noted  in  one,  normal  in  seven,  and  variously  contracted 
and  dilated  in  the  six  remaining.  The  examination  of 
the  much  larger  number  of  cases  in  which  extensive  lacer- 
ation was  complicated  by  other  intracranial  lesions, 
equally  important,  has  been  no  less  confusing  and  unsatis- 
factory. It  has  been  impossible  in  either  class,  after  the 
most  careful  analysis  of  cases,  to  trace  any  connection  be- 
tween the  situation  and  extent  of  the  injury  and  an  atten- 
dant irregularity  of  the  pupils.  It  is  evident  that  pial  and 
cortical  hemorrhages  in  the  region  of  the  middle  fossa  are 
usually  incapable  of  compressing  the  motor  oculi  communis 
nerve ;  and  no  similar  explanation  of  pupillary  contraction  or 
dilatation,  founded  upon  the  fact  of  irritation  or  paralysis  of 
a  nerve  in  its  course  or  at  its  centre  of  origin,  is  possible. 
The  inconstancy  of  the  pupillary  phenomena,  the  varying 
degrees  of  sensitiveness  to  external  irritation,  as  well  as 
the  opposing  conditions  of  contraction  and  dilatation  in  the 
same  case  at  different  times,  while  the  limited  lesion,  the 
laceration,  is  constant  and  unchanged,  indicate  their  source 
in  some  wider  structural  change. 

The  loss  of  consciousness  in  different  degrees,  which 
characterizes  diffuse  general  contusion,  must  be  a  symp- 
tom in  cases  of  laceration,  since  the  general  lesion  is  al- 
ways a  complication.  It  was  usually  manifest  and  often 
long  continued  if  not  permanent  in  the  fatal  cases  which 
were  selected  as  typical  of  this  form  of  injury ;  but  excep- 
tionally there  was  simple  obscuration  of  the  mental  facul- 
ties, and  in  one  instance  the  mental  condition  even  re- 
mained unimpaired.  There  is  no  reason  to  suppose  that 
unconsciousness  is  ordinarily  a  direct  result  of  the  lacera- 
tion; but  it  is  not  demonstrable,  as  it  was  in  case  of  hem- 
orrhages, that  the  suspension  of  consciousness  when  pri- 


126  IN'Tl'RIES    OF   THE    BRAIN    AND    MEMBRANES. 

mary  is  necessarily  due  to  the  accompanying  general 
contusion,  because,  unlike  hemorrhage,  laceration  is  also 
an  instantaneous  lesion.  If,  however,  regard  is  had  to  the 
usual  small  extent  of  a  laceration,  as  compared  with  the 
wide  diffusion  of  the  contusion,  it  seems  the  less  probable 
explanation  in  the  majority  of  cases.  If  the  laceration  in- 
volves a  large  amount  of  tissue,  it  may  be  sufficient  in  it- 
self at  once  to  suspend  consciousness ;  it  then  approaches 
diffused  contusion  in  the  greater  area  affected,  and  in  the 
severity  of  the  psychic  shock  which  it  occasions.  The  un- 
consciousness attributable  to  the  limited  lesion  would  indi- 
cate an  injury  of  great  severity,  and  might,  therefore,  be 
expected  to  be  profound  and  probably  protracted  or  per- 
manent. If  life  is  prolonged,  the  immediate  morbid  con- 
dition will  be  replaced  or  supplemented  after  a  variable 
period  by  characteristic  symptoms.  In  cases  in  which 
consciousness  has  been  retained  from  the  first,  the  mental 
condition  is  often  peculiar;  it  is  not  that  of  partial  con- 
sciousness or  of  absolute  stupor,  but  of  blunted  perception. 
The  patient  seems  lethargic,  but  can  be  aroused  without 
great  difficulty,  and  apparently  comprehends  simple  ques- 
tions in  a  dull  way  and  with  effort,  though  the  effort  is 
quite  likely  to  fall  short  of  compassing  an  answer;  he 
feels  and  sees  and  is  capable  of  effort,  but  scarcely  thinks. 
From  this  condition  he  may  immediately  pass  through 
somnolence  or  complete  unconsciousness  into  coma  and 
death,  or  he  may  at  once  regain  his  mental  equilibrium. 
In  a  considerable  number  of  instances,  in  place  of  this  di- 
rect solution  of  a  psychical  problem,  a  new  series  of  men- 
tal phenomena  are  interposed  between  the  primary  loss  of 
consciousness  or  the  condition  of  lethargy  mentioned  and 
ultimate  recovery  or  death.      In  a  typical  case  delirium  of 


SYMPTOMATOLOGY.  12/ 

some  grade  or  character  follows  or  precedes  restoration  to 
consciousness;  it  may  be  violent  and  simulate  the  alco- 
holic form  of  mania,  but  oftener  the  patient  is  simply  rest- 
less, excitable,  incohere'nt,  or  perhaps  inarticulate  in 
speech,  his  mind  distracted  by  fleeting  fancies,  yet  ame- 
nable to  control.  A  little  later  he  may  recognize  his 
friends,  converse  intelligently  and  coherently,  and  during 
the  day  and  upon  cursory  examination  appear  quite  ration- 
al, though  he  is  still  delirious  and  requiring  mechanical 
restraint  at  night.  He  has  delusions,  fixed  or  transitory, 
and  his  memory  is  defective  or  entirely  wanting  in  regard 
to  circumstances  or  occurrences  which  preceded  his  resto- 
ration to  consciousness.  He  has  often  no  knowledge  of  his 
place  of  residence,  occupation,  or  family;  but,  whatever 
else  he  may  remember  or  forget,  he  is  absolutely  oblivious 
of  all  the  circumstances  attending  his  injury,  and  he  has 
no  apprehension  of  his  present  surroundings.  His  noc- 
turnal delirium  may  soon  disappear  and  eventually  after 
the  lapse  of  weeks  or  even  months,  his  mind  may  become 
clear,  his  memory  be  restored,  and  his  recovery  be  com- 
plete. In  a  certain  proportion  of  similar  cases  the  ter- 
mination is  less  fortunate,  and  some  degree  of  permanent 
dementia  remains.  In  many  others  the  mental  horizon 
never  brightens  after  the  inception  of  delirium,  or,  if  at 
all,  for  a  brief  time  only,  and  death  is  not  long  delayed. 
In  another  type  of  mental  disorder  a  condition  of  apathy 
follows  active  delirium,  and  is  likely  to  be  merged  in  nnal 
unconsciousness.  In  still  other  cases  delirium  is  of  a  mut- 
tering character  from  an  early  stage,  and  is  accompanied 
by  stupor.  Certain  of  these  psychical  symptoms  will  be 
found  hereafter  to  depend  upon  laceration  of  a  definite 
cerebral  region. 


128  INJURIES   OF    THE    BRAIN   AND    MEMBRANES. 

There  is  often  a  want  of  correspondence  observed  be- 
tween the  severity  or  mildness  of  the  invasive  psychical 
symptoms  and  the  final  outcome  of  the  injury.  A  violent 
commencement  has  not  always  involved  an  answerable  se- 
questration, and  so,  too,  a  good  beginning  has  sometimes 
made  a  very  bad  ending;  but  in  either  instance  failure  to 
forecast  the  future  does  not  imply  inability  to  recognize 
pregnant  symptoms.  The  existence  of  the  lesion  may  be 
as  legibly  stamped  upon  the  histories  of  such  cases  as 
upon  those  which  have  run  a  more  conventional  course. 

There  is  a  peculiar  irritability  or  sensitiveness  to  ex- 
ternal impressions  which  is  sometimes  observed  as  a  re- 
sult of  cortical  injury.  It  is  an  exaggerated  response  to 
trivial  irritations  and  disturbances,  which  seems  due,  less 
to  a  hyperaesthesia  of  the  cutaneous  or  other  sensitive  sur- 
faces, than  to  an  abnormal  excitability  of  the  emotional 
centres.  Great  vexation  and  impatience  are  often  mani- 
fested from  slight  irritation,  even  in  the  last  hours  of  life, 
when  the  patient  has  remained  otherwise  motionless  and 
apparently  unconscious  for  a  length  of  time. 

These  varied  manifestations  of  mental  disorder,  while 
occasionally  indicative  of  cerebral  contusion,  are  more 
characteristic  of  laceration.  Delirium  and  stupor,  like 
loss  of  consciousness,  are  to  be  referred  to  the  diffused 
rather  than  to  the  limited  lesion ;  but  the  other  conditions 
of  intellectual  aberration  and  decadence  as  a  result  of 
traumatism  are  almost  exceptional,  unless  there  has  been 
cerebral  wound. 


chapter  III. 

SYMPTOMATOLOGY— Continued. 

The  symptoms  of  contusion  or  laceration  up  to  this 
point  have  been  studied  without  reference  to  their  relation 
to  areas  of  functional  control.  The  peculiarities  of  the 
pulse,  temperature,  and  respiration,  the  variations  of  the 
pupils,  the  loss  of  consciousness,  the  event  of  stupor,  or 
the  access  of  delirium,  have  been  found  to  be  dependent 
upon  the  nature  of  the  lesion  apparently  uninfluenced  by 
its  situation.  An  examination  in  detail  of  the  many  cases 
in  the  appended  series,  in  which  laceration  has  occurred  in 
different  regions  of  the  brain,  affords  some  reason  to  be- 
lieve that  purely  intellectual  and  emotionl  disorders  can 
be  directly  connected  with  the  localization  of  the  injury  in 
a  part  even  more  restricted  than  might  be  supposed  from 
the  results  of  physiological  experiment.  The  number  of 
cases  collated  is  large,  and  their  histories  are  sufficiently 
complete  to  give  value  to  whatever  conclusions  may  be 
justifiable  from  their  analysis.  No  part  of  the  brain  has 
been  so  frequently  involved  in  these  cases  of  fatal  injury 
as  the  frontal  lobes,  the  region  in  which  physiologists 
have  located  the  control  of  the  intellectual  faculties.  The 
influence  of  direct  frontal  injury  upon  the  integrity  of 
thought  and  its  manifestations  confirms  the  correctness 
and  accuracy  of  this  localization. 

The  series  of  two  hundred  and  tv/enty-five  necropsies 
includes  seventy-two  instances  of  laceration  of  one  or  both 
frontal  lobes,  exclusive  of  those  pistol-shot  wounds  in 
9 


130  INJURIES   OF    THE    BRAIN   AND    MEMBRANES. 

which  almost  instantaneous  death  precluded  history.  In 
thirty-three  of  these  cases  morbid  mental  conditions  had 
been  inappreciable  by  reason  of  primary  and  permanent 
unconsciousness ;  and  in  eleven  others  an  early  fatal  issue, 
preceded  by  only  partial  consciousness  or  the  existence  of 
delirium  from  the  general  cortical  lesion,  made  the  recog- 
nition of  indications  of  the  local  injury  equally  impossible. 
Twenty-eight  cases  remain,  in  which  the  attendant  condi- 
tions permit  an  estimate  of  the  direct  results  of  frontal 
lesion.     These  comprise : 

Laceration  of  the  left  frontal  lobe,  .  .  11 

"  "     "     right     "       "        .         .  7 

"  "     both  frontal  lobes,    .         .  10 — 28 

I.  Laceration  of  the  Left  Frontal  Lobe. 

1.  Stupor  with  incoherence  preceded  delirium  on  the 
second  day.  Lesion  confined  to  cortex  of  the  inferior  sur- 
face. 

2.  Patient  sent  to  an  asylum  for  the  insane  on  the 
eighth  day,  with  delusions  and  other  manifestations  of 
mental  aberration.  Lesion  confined  to  cortex  of  the  infe- 
rior surface. 

3.  Delusions  on  the  third  day.  Lesion  confined  to 
cortex  of  the  inferior  surface. 

4.  Sensory  aphasia  and  mental  aberration  on  the  first 
day.  Laceration  of  greater  part  of  the  inferior  sur- 
face; also  of  the  first  and  second  left  temporal  convolu- 
tions. 

5.  Mental  decadence  with  mild  delirium  till  death  on 
the  fourteenth  day.  Extensive  laceration  of  the  antero- 
superior  and  inferior  surfaces. 


SYMPTOMATOLOGY.  1 3  I 

6.  No  primary  loss  of  consciousness,  but  inability  of 
com  prehension.     Excavation  of  greater  part  of  the  lobe. 

7.  Mental  aberration  and  delusions  till  the  thirteenth 
day,  and  afterward  stupor.  Excavation  of  prefrontal  re- 
gion, with  an  extension  of  clot  to  the  posterior  border  of 
the  lobe. 

8.  Constant  mild  delirium  with  an  entire  lack  of  com- 
prehension of  surrounding  conditions.  Small  central  lac- 
eration posteriorly. 

9.  Ability  to  answer  only  a  limited  number  of  ques- 
tions correctly,  and  answers  mainly  ejaculatory.  Subcor- 
tical laceration,  one  and  one-half  inches  by  three-fourths 
of  an  inch  in  diameter,  in  anterior  region. 

10.  Delusions  on  the  fourth  day,  delirium  at  night. 
Laceration  of  the  inferior  surface. 

1 1 .  Stupor,  lack  of  attention  and  of  power  of  com- 
prehension; delirium  at  night.  Laceration  of  inferior 
surface. 

IL  Laceration  of  the  Right  Frontal  Lobe. 

1.  Primary  unconsciousness  lasting  a  few  hours. 
Mental  condition  then  normal  till  sudden  recurrence  of 
coma  on  the  seventh  day.  Laceration  of  the  inferior  sur- 
face. 

2.  No  symptoms  of  mental  disorder  till  the  occurrence 
of  violent  delirium  on  the  second  day.  Subcortical  lacera- 
tion in  middle  portion  of  the  lobe,  with  rupture  of  the 
inferior  surface. 

3.  Transient  and  partial  primary  loss  of  consciousness; 
no  other  mental  disorder  till  final  coma.  Deep  laceration 
of  superior  surface,  extending  nearly  to  lateral  ventricle. 

4.  Mental    condition    normal   for   first   twelve   hours; 


132  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

then  convulsions,  unconsciousness,  and  delirium.  Exca- 
vation of  inferior  and  outer  part  of  the  lobe;  cavity  as 
large  as  a  pigeon's  egg. 

5.  Mental  condition  normal  for  several  hours;  then  a 
single  convulsion,  followed  by  stupor  and  delirium,  which 
continued  till  the  eleventh  day;  some  questions  intelli- 
gently answered  in  an  interval  before  the  occurrence  of 
final  coma.  Excavation  of  inferior  portion  of  prefrontal 
region. 

6.  Mental  condition  normal  till  second  day ;  later  men- 
ingitis.    Laceration  of  inferior  surface. 

7.  Mental  condition  normal  till  death  at  end  of  thirty- 
three  days.  Pistol-shot  wound.  Previous  melancholia 
continued. 

III.  Laceration  of  Both  Frontal  Lobes. 

1.  Stupor  during  first  three  days;  mental  condi- 
tion apparently  normal  on  the  fourth  day;  later,  stupor, 
convulsions,  and  coma.  Laceration  of  inferior  sur- 
faces. 

2.  Mental  condition  normal  on  second  day;  patient 
apathetic  on  sixth  and  seventh  days ;  final  coma  on  the 
eighth  day.     Subcortical  disintegration  of  both  lobes. 

3.  A  fixed  delusion  conceived  on  the  second  day  con- 
tinued till  death  in  the  fourth  week ;  other  delusions  which 
were  transient.  Laceration  of  the  inferior  surface  of  the 
left  lobe,  extending  through  and  below  the  cortex  and 
across  the  median  line. 

4.  Delusions  and  loss  of  memory  for  five  days ;  mental 
condition  normal  on  the  sixth  day ;  later  progressive  men- 
tal impairment  till  death  at  end  of  the  fourth  week.  Mul- 
tiple laceration  of  the  superior  left  prefrontal  region  and 


SYMPTOMATOLOGY.  1 33 

limited  contusion.     Slight  laceration  of  the  external  sur- 
face of  the  right  lobe. 

5.  Apathy,  rambling  speech,  and  delusions  in  the 
fourth  week,  which  continued  till  death,  two  weeks  later. 
Laceration  of  inferior  surface  of  each  lobe. 

6.  Mental  condition  apathetic  in  an  unusual  degree, 
but  rational.  Death  on  the  thirteenth  day.  Pistol-shot 
wound  through  central  frontal  region. 

7.  Patient  irrational,  but  not  delirious.  Death  on  the 
second  day.      Laceration  of  inferior  surface  of  each  lobe. 

■  8.  Mental  condition  normal  for  two  hours,  when  final 
stupor  and  coma  supervened.  Disintegration  of  anterior 
half  of  left,  and  of  whole  of  right,  inferior  surface. 

9.  Primary  mental  aberration,  delusions  on  the  second 
day;  later,  meningitis.  Lacerations  of  the  inferior  sur- 
face of  each  lobe;  two  upon  the  left  lobe  extending 
through  the  cortex;  those  of  the  right  side  smaller  and 
more  superficial. 

10.  Patient  not  under  observation  till  two  days  after 
injury,  and  was  then  semi-conscious ;  when  aroused,  men- 
tal processes  slow;  later,  progressive  stupor  and  coma. 
Disintegration  of  both  prefrontal  regions  from  pistol-shot 
wound. 

The  cases  to  which  reference  is  made  have  been  other- 
wise described  in  their  general  histories,  which  are  in- 
cluded in  the  appended  series.  The  associated  lesions 
have  been  here  disregarded  in  each  instance  as  not  related 
to  the  present  matter  of  inquiry.  In  the  eleven  cases  in 
which  frontal  laceration  was  confined  to  the  left  lobe, 
there  was  mental  aberration  or  deficiency,  apart  from 
mere  stupor  or  delirium,  in  every  one ;  while  in  the  seven 
in  which  laceration  was  confined  to  the  right  lobe,  it  was 


134  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

observed  in  none.  In  the  ten  cases  in  which  frontal  lacera- 
tion involved  bcth  lobes,  and  in  which  specific  mental  dis- 
turbance might  be  expected  from  the  implication  of  the 
left,  it  was  observed  in  eight;  in  one  of  the  two  in  which 
the  mental  condition  had  not  thus  indicated  the  seat  and 
nature  of  the  lesion,  only  two  hours  had  elapsed  before 
the  supervention  of  final  coma;  in  the  other,  there  is  no 
reason  apparent  in  the  history  for  its  exemption  from  the 
mental  disorder  common  to  all  the  others  in  which  lesion 
of  the  left  lobe  existed.  It  is  possible  that  more  care- 
ful study  of  symptoms  might  have  brought  the  excep- 
tional case  within  the  control  of  what  seems  to  be  a  gen- 
eral law  of  relationship  between  a  very  limited  region  of 
the  brain  and  the  manifestation  of  the  higher  psychical 
phenomena.  In  view  of  the  rapid  progress  made  in  many 
instances  toward  a  fatal  issue,  and  of  the  brief  and  imper- 
fect opportunities  afforded  in  others  for  the  appreciation  of 
mental  peculiarities,  the  results  of  analyses  of  individual 
cases  are  remarkably  consistent  with  each  other  and  point 
to  a  highly  probable  if  not  positive  conclusion.  The  nota- 
tion of  histories  was  made  in  the  greater  part  of  this  group 
of  cases  before  it  was  suspected  that  a  direct  relation  ex- 
isted between  destructive  lesions  of  the  left  frontal  lobe 
and  special  intellectual  disorders  disconnected  with  general 
disturbances  or  default.  If  observations  have  been  re- 
corded in  less  detail  than  might  have  been  expected,  had 
a  definite  purpose  been  held  in  view,  they  at  least  escape 
the  imputation  of  having  been  even  unconsciously  colored 
by  preconceived  opinion. 

The  lacerations  were  not  always  of  the  same  character, 
situation,  or  extent.  All  but  one  involved  the  anterior  re- 
gion of  the  lobe.     Thirteen  had  led  to  a  more  or  less  com- 


SYMPTOMATOLOGY.  I35 

plete  disintegration,  either  directly  or  as  an  effect  of  hemor- 
rhage. Thirteen  of  the  cortical  injuries  were  confined  to 
the  base,  and  the  two  others  were  wholly  or  in  part  upon 
the  antero-superior  surface.  The  lesions  were  cortical  and 
subcortical  in  case  of  either  lobe,  and  when  both  lobes  were 
implicated  the  dual  injuries  were  usually  of  the  same  char- 
acter. The  S3'mptoms  held  some  relation  to  the  situation 
and  extent  of  the  lesion.  In  the  subcortical  excavations 
and  disintegrations,  there  was  abrogation  of  mental  power 
rather  than  aberration  in  its  manifestations,  the  patient's 
condition  being  sluggish  and  apathetic.  In  the  cortical 
lacerations,  in  place  of  apparent  default  of  intelligence, 
there  were  perverted  memory,  lack  of  attention  and  con- 
trol, incoherence,  delusions,  or  the  stupor  which  comes 
from  confusion  rather  than  paucity  of  ideas ;  the  mind  was 
alert  to  external  impressions,  though  they  were  not  always 
rightly  comprehended.  These  distinctions  which  are  gen- 
eral are  by  no  means  absolute.  The  localizing  symptoms 
would  be  naturally  less  pronounced  or  absent  in  cases  in 
which  the  frontal  lesion  was  trivial,  or  in  which  from  the 
severity  of  the  local  injury  death  occurred  at  an  early 
period,  though  this  did  not  always  prove  to  be  the  fact. 
If  recovery  ensued,  the  longer  duration  of  symptoms  should 
increase  the  probability  of  determining  with  certainty  the 
presence  or  absence  of  specific  mental  disorder.  This  is 
exemplified  in  several  of  the  appended  histories,  in  some 
of  which  the  exact  frontal  lesion  was  well  assured  or  posi- 
tively ascertained. 

The  converse  proposition,  that  laceration  of  the  left 
frontal  lobe  is  the  sole  traumatic  lesion  which  occasions  a 
direct  loss  or  derangement  of  intellectual  function,  is,  so 
far  as  can  be  judged  from  a  study  of  the  same  series  of 


136  INJURIES   OF    THE    BRAIN   AND    MEMBRANES. 

cases,  only  a  little  less  absolutely  true.  In  the  two  hundred 
and  twenty-five  necropsies,  death  had  been  preceded  by 
such  deficiency  or  derangement  in  four  instances  in  which 
this  injury  was  not  disclosed.  In  one  of  these,  a  case  of  pis- 
tol-shot wound  of  a  parietal  lobe,  some  slowness  of  compre- 
hension was  added  to  a  hysterical  melancholia  which  had 
led  to  a  suicidal  attempt ;  this  may  be  properly  excluded,  as 
mental  disease  existed  before  the  reception  of  injury.  In 
each  of  the  other  three,  mental  decadence  was  evident;  in 
two,  general  hyperaemia  and  oedema  were  excessive,  and  in 
the  third  a  large  localized  subarachnoid  serous  effusion 
compressed  the  frontal  lobes.  These  exceptional  cases  are 
scarcely  more  than  two  per  cent,  of  the  whole  number  of 
intracranial  injuries,  verified  by  necropsy,  in  which  the 
frontal  lobes  were  not  the  seat  of  destructive  injury ;  and 
in  them  the  frontal  lobes,  though  not  wounded,  were  in  one 
instance  the  parts  solely  affected  by  a  limited  lesion,  and  in 
the  other  two  were  included  in  a  general  lesion  of  excessive 
severity.  There  were  no  instances  in  which  a  laceration  of 
any  other  cerebral  region  was  attended  by  characteristic 
mental  changes. 

The  differences  in  symptoms  as  the  right  or  the  left 
frontal  lobe  is  the  seat  of  laceration  are  further  exemplified 
in  the  histories  of  pistol-shot  wounds  of  the  brain.  The 
whole  number  of  cases  which  have  been  heretofore  re- 
ported from  English  and  American  sources  during  the  years 
1879  to  1895  inclusive  is  probably  not  more  than  one-hun- 
dred and  fifty,  of  which  it  has  been  possible  to  collate 
for  the  present  purpose  one  hundred  and  ten.  Fifty-eight 
of  this  number  involved  the  frontal  lobes;  twenty-six 
of  these  were  limited  to  the  right,  and  twenty-four  to  the 
left  lobe ;  eight  included  both  lobes.     The  cases  which  ter- 


SYMPTOMATOLOGY.  1 3/ 

minated  in  recovery,  and  on  tliat  account  probably  deemed 
most  worthy  of  record,  were  in  large  proportion ;  and  in 
them  the  situation  of  the  lesion  was  made  certain  by  the  use 
of  the  probe,  by  operation  for  the  removal  of  the  ball,  or  by 
the  appearance  of  brain  matter  at  the  surface.  Not  one  of 
the  twenty-six  cases  in  which  the  cerebral  wound  was  con- 
fined to  the  right  side  presented  at  any  time  any  symptom 
of  mental  or  emotional  disturbance,  aside  from  the  stupor 
or  delirium  which  is  characteristic  of  general  contusion. 
In  thirty-two  cases  the  ball  traversed  the  left  frontal  lobe, 
in  eight  of  which  there  are  no  means  of  determining  the 
mental  condition,  the  loss  of  consciousness  having  been 
permanent,  or  the  general  symptoms  entirely  unnoted. 
In  thirteen  of  those  remaining,  manifestations  of  mental 
derangement  were  distinctly  eyident.  In  several  of  the 
others  the  mental  condition  v/asktot  specifically  mentioned 
and  the  histories  were  otherwise  deficient.  There  are 
still  a  limited  number  of  cases  in  which  with  a  wound  of 
the  left  lobe  the  mind  was  apparently  unimpaired ;  some 
of  these  are  stated  to  have  exhibited  some  form  or  degree 
of  aphasia,  and  in  nearly  or  quite  all  of  them  the  lesion 
was  of  the  posterior  part  of  the  lobe.  The  series  of  cases 
as  a  whole  seems  to  justify  the  conclusion  that  pistol-shot 
wounds,  a  class  of  injuries  in  which  lesion  is  more  strictly 
localized  than  in  others  and  consequently  well  suited  to 
purposes  of  inductive  study,  indicate  that  intellectual  and 
emotional  derangements  are  symptomatic  not  only  of  lesion 
of  the  left  frontal  lobe  but  also  of  its  anterior  and  central 
portions.  It  is  also  noticeable  that  in  cases  of  general  trau- 
matism the  injuries  when  superficial  were  usually  upon 
the  inferior  surface,  which  has  been  classed  as  a  latent 
area. 


138  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

In  summarizing  the  results  of  this  examination  of  a 
series  of  one  hundred  and  thirty  cases  of  wound  of  the 
frontal  lobes  it  appears : 

1.  That  in  nearly  every  instance  in  which  conscious- 
ness was  retained  or  regained,  and  the  mental  faculties  were 
not  perverted  by  general  delirium,  laceration  involving  the 
left  lobe  was  attended  by  default  of  intellectual  control,  and 
that  the  lesion  was  usually  of  the  anterior  region  and  im- 
plicated its  inferior  surface.  Subcortical  disintegration 
was  characterized  by  abrogation  of  mental  power,  and 
superficial  laceration  by  aberration  in  its  manifestations. 

2.  That  in  every  instance  in  which  laceration  was 
confined  to  the  right  lobe  the  mental  faculties  remained 
unaffected,  except  as  they  were  obscured  by  stupor  or 
delirium  occasioned  by  coincident  general  lesion. 

3.  That  compression  or  contusion  of  the  left  lobe  only 
exceptionally  produced  specific  intellectual  disturbances. 
This  generalization  is  based  upon  an  examination  of  the 
entire  series  of  one  hundred  and  thirty  cases,  in  which  the 
history  was  confirmed  by  necropsy. 

There  are  other  symptoms  due  to  cerebral  laceration, 
which,  like  those  connected  with  the  mental  condition,  in- 
dicate with  comparative  certainty  the  situation  as  well  as 
the  nature  of  the  lesion.  These  are  mainly  though  not 
exclusively  disorders  of  the  motor  function.  It  is  con- 
ceded that  a  motor  zone  contiguous  to  the  Rolandic  fissure 
in  the  human  brain,  and  analogous  to  a  similar  area  ex- 
perimentally demonstrated  by  comparative  physiologists, 
has  been  verified  by  many  observations  of  the  effects  of 
both  idiopathic  and  traumatic  lesions.  This  is  illustrated 
also  in  the  present  series  of  cases,  but  in  a  relatively  small 
proportion   of  their  whole  number,  since   violence,   even 


SYMPTOMATOLOGY.  1 39 

when  inflicted  at  the  vertex,  is  so  generally  transmitted  to 
the  base,  where  its  limited  destructive  effect  is  exerted, 
that  the  motor  region  is  likely  to  escape  injury.  The  na- 
ture of  the  paralyses  which  follow  the  implication  of  the 
several  centres  of  control  in  this  area,  and  their  sympto- 
matic significance,  are  too  well  understood  to  require  more 
specific  mention. 

Not  only  abrogation  or  abridgment  of  muscular  power, 
but  muscular  incoordination  may  point  to  the  situation  as 
well  as  to  the  fact  of  cerebral  laceration.  The  occurrence 
in  this  way  of  motor  aphasia  from  lesion  of  the  third  left 
frontal  convolution,  or  of  agraphia  from  lesion  of  some  con- 
nected area,  are  among  the  unquestioned  results  of  trauma- 
tism. It  is  doubtful  if  ataxia  is  ever  occasioned  by  cere- 
bellar laceration.  It  was  observed  in  no  instance  in  the 
appended  series  of  cases  in  which  this  lesion  existed,  and  it 
is  probable  that  no  injury  of  this  part  can  occur  sufficiently 
extensive  to  produce  characteristic  symptoms,  without 
complicating  conditions  in  which  they  must  necessarily  be 
lost. 

The  occurrence  of  clonic  contractions  or  of  tetanic 
spasm,  either  general  or  limited,  is  also  symptomatic  of 
cerebral  laceration  and  to  some  extent  indicative  of  the  re- 
gion involved.  The  value  of  these  muscular  disturbances 
as  a  general  and  localizing  indication  may  be  estimated 
from  a  statistical  view  of  the  cases  of  the  appended  series 
in  which  they  have  been  observed  and  the  attendant  post- 
mortem conditions  noted.  There  were  thirty  instances  of 
general  or  unilateral  convulsions,  which  in  twenty-seven 
resulted  from  cerebral  laceration,  and  this  in  twenty  was 
upon  the  right  side  of  the  brain.  The  temporal  lobes 
were  involved  in  twelve  cases,   the  frontal  in   nine,    the 


I40  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

optic  thalami  in  five,  and  the  cerebellum  or  corpora  striata 
in  the  other  four.  The  laceration  was  not  often,  though 
occasionally,  confined  to  a  single  lobe.  In  the  great  ma- 
jority of  cases  the  essential  lesion  was  in  the  temporal  or 
frontal  region  and  might  be  cortical  or  subcortical,  and 
when  cortical  was  somewhat  oftener  than  otherwise  upon 
the  inferior  surface.  There  were  twenty-three  cases  in 
v;hich  minor  local  or  general  convulsive  movements  oc- 
curred, fifteen  of  which  attended  laceration  of  the  frontal 
or  temporal  region.  There  was  no  constant  relation  be- 
tween the  situation  of  the  lesion  and  the  side  upon  which 
spasmodic  movements  were  produced,  or  between  its  oc- 
currence upon  one  or  both  sides  of  the  brain  and  their 
unilateral  or  bilateral  character.  There  were  twenty- 
eight  cases  in  which  muscular  rigidity  was  a  symptom ;  it 
was  general  in  ten,  in  eight  of  which  there  was  frontal  or 
temporal  laceration,  and  it  was  limited  in  eighteen,  with 
similar  laceration  in  seven,  and  of  a  corpus  striatum  in 
one.  There  were  thus  eighty-one  cases,  or  more  than 
one-third  of  all  those  subjected  to  post-mortem  examina- 
tion, in  which  some  form  of  disordered  muscular  function 
was  a  symptom;  and  of  these,  in  fifty-eight  there  was 
cerebral  laceration,  in  fifty-one  of  which  it  was  essentially 
of  the  frontal  or  temporal  lobes.  It  will  be  further  ob- 
served that  the  probability  of  fronto-temporal  laceration 
increases  with  the  severity  of  the  muscular  disturbance. 
General  or  unilateral  convulsions  depended  upon  laceration 
in  twenty-seven  of  the  thirty  cases,  and  in  twenty-one  this 
was  of  the  frontal  or  temporal  lobes,  or  of  both  together; 
simple  muscular  rigidity  was  associated  with  laceration  in 
scarcely  more  than  half  the  cases  in  which  it  occurred. 
The   exceptional   dependence    of    convulsive   movements 


SYMPTOMATOLOGY.  I4I 

upon  hemorrhage  or  meningeal  effusions  may  be  properly- 
deferred  to  a  later  consideration  of  diagnosis. 

The  more  inaccessible  regions  of  the  brain  are  not  ex- 
empt from  destructive  alteration,  but  distinctive  symptoms 
have  not  been  separable  from  those  of  associated  lesions. 
In  seven  cases  of  laceration  and  limited  contusion  of  the 
corpora  striata,  varying  from  a  minute  extravasation  to 
complete  disintegration,  the  most  constant  symptom  was 
morbid  muscular  contraction,  which  was  absent  in  only  one, 
that  of  a  pistol-shot  wound  with  death  before  reaction.  In 
each  there  were  complications  sufficient  to  account  for  the 
disordered  muscular  action,  as  a  frontal  or  parietal  lacera- 
tion, a  hemorrhage,  or  dural  wounds.  In  four  the  lesion 
extended  to  the  optic  thalamus.  Complicating  laceration 
failed  but  once,  and  was  replaced  by  a  pial  hemorrhage. 
The  temperature  scarcely  exceeded  102°;  in  a  case  of  com- 
plete disintegration  of  the  right  and  much  laceration  of 
the  left  corpus  striatum,  it  rose  in  the  eight  hours  which 
preceded  death  only  to  102.2°.  In  the  one  instance  in 
which  it  attained  a  considerable  elevation,  the  lesion  was 
insignificant.     Paralysis  was  never  observed. 

In  the  seven  cases  in  which  an  optic  thalamus  was 
lacerated  without  lesion  of  the  corpus  striatum,  there  were 
general  convulsions  in  four,  opposite  unilateral  convulsions 
following  muscular  rigidity  in  two,  and  convulsive  move- 
ments of  the  arms  in  the  seventh.  The  temperature  was 
higher,  rising  to  107°+,  107°,  io5°+>  ^^3°  ^^^  io2°-|-. 
The  complications  in  four  were  extensive;  a  relatively 
large  extravasation  into  the  pons,  a  deep  laceration  of  the 
frontal  lobe,  and  a  large  cortical  hemorrhage,  in  one; 
cortical  laceration  of  the  frontal  and  a  wide  and  deep 
laceration  of  the  temporal  lobe  in  the  second ;  pial  hemor- 


142  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

rhage  in  the  third ;  and  an  excessive  cerebral  oedema  in 
the  fourth.  In  the  case  last  mentioned  there  were  a  notice- 
able weakness  of  the  muscles  of  the  trunk,  post-cervical 
muscular  rigidity  as  well  as  general  convulsions,  loss  of 
fsecal  and  urinary  control,  and  marked  mental  decadence, 
though  there  were  no  hemorrhages  and  no  lacerations. 
The  fifth  case  was  remarkable,  both  from  the  severity 
of  the  lesions  of  the  thalami  and  from  the  fact  of 
their  comparative  isolation.  The  left  thalamus  was 
much  contused  in  the  anterior  portion  of  its  inner  sur- 
face, and  the  right  thalamus  extensively  lacerated  upon  its 
superior  surface.  There  were  contusion  of  the  fornix  an- 
teriorly with  punctate  extravasations,  a  small  clot  not  larger 
than  a  filbert  in  the  centre  of  the  left  cerebellum,  and  a 
moderate  general  contusion.  The  disorders  of  muscular 
action  were  confined  to  the  left  side ;  there  were  temporary 
rigidity  upon  admission,  which  was  relieved  by  the  eleva- 
tion of  a  depressed  osseous  fragment,  violent  unilateral 
convulsions  on  the  second  day,  continuing  for  three  hours, 
and  later  permanent  rigidity.  The  temperature  in  the 
last  twenty-four  hours  of  life  ranged  from  i05°-|-  to  107°. 

There  were  two  instances  of  laceration  of  the  fornix, 
one  in  its  anterior  and  the  other  in  its  posterior  portion, 
neither  of  which  was  of  great  extent.  In  the  first,  which 
complicated  frontal  laceration  and  general  contusion,, the 
prominent  symptoms  were  delirium  and  mental  enfeeble- 
ment,  with  high  temperatures.  In  the  second,  in  which 
copious  subarachnoid,  ventricular,  and  parenchymatous 
serous  effusions  were  notable  complications,  the  unusual 
feature  in  the  case  was  the  extraordinary  variations  in  both 
axillary  and  rectal  temperatures. 

Lacerations  of  the  gyrus  fornicatus  occurred  in  three 


SYMPTOMATOLOGY.  I43 

cases,  in  one  of  which  it  was  trivial;  in  a  second,  implicat- 
ing its  anterior  portion  and  incidental  to  severe  laceration 
of  the  left  frontal  lobe,  there  was  temporary  anaesthesia  of 
the  right  upper  extremity;  and  in  the  third,  which  was  in- 
dependent and  situated  in  the  middle  third  of  the  convolu- 
tion, general  sensation  was  markedly  diminished  on  the 
fourth  and  last  day  of  life. 

There  were  five  cases  in  which  laceration  with  extrava- 
sation occurred  in  the  substance  of  the  pons.  The  lesion 
in  each  was  limited,  the  largest  clot  not  exceeding  the 
size  of  a  pea.  There  were  no  disturbances  of  muscular 
action,  except  in  one  previously  mentioned  as  complicat- 
ing thalamic  laceration,  and  death  was  occasioned  by 
cortical  or  meningeal  hemorrhage. 

This  series  of  limited  lesions  of  the  deeper  portions  of 
the  brain  is  too  restricted  in  number,  and  the  complica- 
tions are  too  serious,  to  justify  any  inferences  as  to  the 
existence  of  distinctive  topical  symptoms.  The  injuries  of 
the  corpora  striata  and  optic  thalami  seemed  to  be  attended 
in  almost  every  instance  by  some  muscular  disorder  and  an 
elevation  of  temperature,  which  in  case  of  the  optic  thalami 
was  pronounced ;  and  lacerations  of  the  fornix  by  a  diminu- 
tion of  ordinary  sensibility ;  but  these  indications  even  if 
invariable  still  fail  of  a  definite  localizing  value. 

There  is  still  a  pathic  condition  to  be  considered,  which 
is  at  once  indicative  of  the  existence  of  laceration  and  of 
its  situation.  Sensory  aphasia  has  been  satisfactorily  de- 
termined by  neurologists  to  depend,  in  idiopathic  disease, 
upon  lesion  of  the  lower  parietal  and  upper  temporal  re- 
gions, or,  more  definitely,  of  the  first  temporal  and  supra- 
marginal  convolutions  and  angular  gyrus.  The  traumatic 
destruction  of  the  same  parts  must  necessarily  lead  to  the 


144  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

same  results.  It  is  somewhat  remarkable  that,  while  the 
disturbances  of  speech  have  not  been  infrequent  in  the  re- 
covering cases,  the  appended  series  has  afforded  but  a 
single  example  among  those  which  were  fatal.  In  this 
one  instance,  which  was  characteristic,  the  first  left  tem- 
poral convolution  was  lacerated  through  the  whole  thick- 
ness of  the  cortex,  for  a  length  of  one  and  a  half  inches, 
which  included  the  second  and  part  of  its  third  fifths,  esti- 
mated from  its  anterior  extremity,  and  in  its  middle  por- 
tion the  laceration  involved  the  second  convolution.  This 
injury  was  limited  to  the  exact  width  of  the  two  convolu- 
tions, and  was  covered  by  the  unruptured  arachnoid  mem- 
brane. Smaller  lacerations  existed  at  the  tip  and  upon  the 
inferior  surface  of  this  lobe,  and  at  the  tip  of  the  right 
lobe.  In  the  remaining  cases,  seventy-five  or  more  in 
number,  in  which  the  temporal  lobes  were  lacerated,  there 
were  twenty-five  in  which  the  external  surface,  which  in- 
cludes centres  of  speech,  was  affected ;  in  fourteen  of  these, 
primary  and  permanent  unconsciousness  precluded  the 
recognition  of  possible  impairments  of  this  faculty  in  any 
of  its  elements;  in  ten  in  which  the  retention  or  the  re- 
turn of  consciousness  permitted  the  exercise  of  speech,  the 
position  and  extent  of  the  lesion  in  each  was  thus  deter- 
mined : 

1.  External  border — small — left. 

2.  External  surface — small — left. 

3.  Middle  of  first  convolution — right. 

4.  Middle  of  second  convolution — left. 

5.  Anterior  one-fourth  of  second  convolution — left. 

6.  Posterior  part  of  third  convolution — small — left. 

7.  Posterior  one-third  of  first  and  second  convolution — 
riofht. 


SYMPTOMATOLOGY.  145 

8.  Anterior  extremity  of  first  and  second  and  middle 
of  first  convolutions — left, 

9.  Nearly  the  whole  of  second  and  third,  and  a  little  of 
first  convolutions — atrophy  and  induration  of  the  whole 
lobe — right. 

10.  Complete  subcortical  excavation — left. 

There  were  in  addition  two  cases  of  limited  contusion. 

1 .  Posterior  part  of  first,  second,  and  third  convolutions, 
covering  an  area  of  one  square  inch — yellowish  in  color 
and  studded  with  hard  punctate  extravasations — right. 

2.  Middle  portion  of  first  convolution  and  adjacent 
parietal  region — dark  cortical  discoloration  and  punctate 
extravasations — left. 

There  were  no  aphasic  conditions  in  any  of  these  lacer- 
ations or  contusions,  which  in  view  of  exceptional  cases 
include  those  of  the  right  as  well  as  of .  the  left  side.  It 
would  seem  from  these  instances  that  absolute  destruction 
of  tissue  within  the  whole  of  an  exactly  limited  area  is 
essential  to  specific  impairments  of  speech ;  and  that  sub- 
cortical disintegration,  however  complete  in,  extent  or  de^ 
gree,  or  alteration  of  cortical  structure  by  limited  contusion,, 
however  exact  in  its  conformation  to  the  limits  of  the 
centre  of  control,  is  insufficient.  The  comparative  fre,- 
quency  of  some  form  of  aphasia  in  recovering  cases  is  a 
probable  result  of  general  rather  than  of  local  lesion.  An 
examination  of  the  history  of  such  cases  will  usually  point 
to  the  existence  of  general  contusion,  and  the  often  early 
as  well  as  perfect  restoration  of  function  indicates  cirr 
culatory  disturbance  rather  than  structural  alteration. 

There  was  no  appreciable  default  or  disorder  of  the 
special  senses  in  any  of  the  temporal  lacerations,  though 
the  supposed  auditory,    olfactory,   and   gustatory  centres 


146  INJURIES   OF   THE    BRAIN    AND    MEMBRANES. 

were  sometimes  involved.  In  certain  recovering  cases 
there  seemed  reason  to  believe  that  occasional  defects  of 
hearing,  smell,  or  taste  were  due  to  central  lesion.  The 
occipital  visual  area  was  rarely  the  seat  of  limited  injury. 

The  conjugate  deviation  of  the  head  and  eyes,  or  of 
the  eyes  alone,  when  observed  in  traumatic  cases  is  not  in- 
dicative of  a  lesion  such  as  might  naturally  be  expected 
from  the  result  of  experimentation ;  nor  has  it  been  asso- 
ciated with  the  conditions  which  have  been  recognized  in 
idiopathic  disease.  The  experimental  destruction  of  the 
posterior  portion  of  a  frontal  lobe  occasions  temporary  de- 
viation to  the  corresponding  side,  and  its  irritation  a  devia- 
tion in  the  opposite  direction.  In  cases  of  acccidental  in- 
jury in  which  this  symptom  has  occurred  the  lesions  have 
been  varied,  but  in  no  instance  have  included  posterior 
frontal  laceration.  Idiopathically  it  occurs  in  connection 
with  epileptic  seizures;  and,  when  paralytic,  with  more 
general  paralysis  caused  by  hemorrhage.  In  the  com- 
paratively few  instances  in  which  it  was  noted  in  the  ap- 
pended series,  no  other  considerable  paralysis  existed,  and 
when  death  resulted,  as  it  usually  did,  the  lesion  was  found 
to  be  indifferently  a  general  contusion  with  oedema,  lacera- 
tion, meningitis,  or  some  form  or  degree  of  hemorrhage; 
and  almost  invariably  different  lesions  were  so  complicated 
with  each  other  as  to  render  impossible  the  identification 
of  either  one  as  the  direct  cause  of  the  symptom.  The 
exact  manner  of  implication  of  the  nerve  nucleus  is  not 
evident.  The  prominent  associated  condition  was  a  pro- 
found unconsciousness,  and  the  essential  lesion  was  oftener 
general  than  limited.  In  a  minor  number  of  cases  re- 
covery ensued,  and  in  them  consciousness  was  not  lost. 

The  enumeration  of  symptoms  may  be  ended  with  one 


SYMPTOMATOLOGY.  I47 

of  the  most  important  of  the  general  indications,  the  loss 
of  control  over  the  action  of  the  bladder  and  rectum.  It 
is  impossible  to  estimate  its  numerical  frequency,  for,  if 
these  receptacles  are  empty  at  the  time  the  brain  injury 
is  inflicted,  and  if,  as  often  happens  in  recorded  cases,  life 
is  afterward  measured  by  hours  or  perhaps  by  minutes, 
this  diagnostic  point  is  necessarily  lost.  If  such  explicable 
cases  are  excluded,  it  may  be  said  to  be  very  generally  ob- 
served as  a  symptom  of  laceration.  It  has  been  as  often 
noted  in  the  absence  of  any  form  of  paralysis  as  other- 
wise, and  when  consciousness  has  been  retained;  and 
though  some  form  of  mental  impairment  may  have  always 
coexisted,  the  same  loss  or  aberration  of  mental  power 
when  due  to  other  lesions  has  not  been  characterized  by 
this  particular  functional  incapacity.  The  lacerations  have 
been  both  cortical  and  subcortical,  and  have  involved  all 
the  lobes  and  all  regions  of  the  brain,  so  that  the  direct 
cause  of  this  lack  of  control  would  seem  to  be  any  wound 
of  the  cerebral  parenchyma,  whether  or  not  it  may  be  ulti- 
mately traced  to  some  special  centre. 

The  direct  symptoms  of  intracranial  traumatism  have 
been  described  as  they  occur  in  fatal  cases,  and  as  they 
have  been  verified  by  necropsic  examination;  they  have 
been  in  the  main  disregarded  as  they  are  manifest  in  recov- 
ering cases,  in  which  positive  evidence  of  the  pathogenic 
conditions  upon  which  they  depend  is  usually  want- 
ing. It  is  probable  that  no  esential  differences  in  symp- 
tomatology exist,  except  in  degree,  and  in  many  instances 
the  early  progress  of  the  case  is  not  at  all  indicative  of  the 
final  result.  There  is  no  symptom  which  occurs  in  fatal 
cases  which  may  not  be  noted  in  those  destined  to  a  more 


148  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

favorable  termination,  unless  it  may  be  the  infrequency  of 
respiration  which  follows  compression  of  the  medulla,  and 
none  less  characteristically  present,  except  an  extreme 
elevation  of  temperature.  Even  in  temperature  the  dis- 
tinction is  not  absolute;  not  only  in  the  beginning  but  for 
many  days  it  may  be  higher  in  a  recovering  case  than  in 
one  which  is  to  end  in  death,  but  in  general  its  range  is 
less,  and  it  has  rarely  attained  and  never  exceeded  a  limit 
of  105°,  as  it  has  been  observed  in  the  series  of  five  hun- 
dred cases  upon  which  these  conclusions  have  been  based. 
The  direct  results  of  lesion  in  all  cases,  whatever  the  final 
issue,  are  shock,  circulatory  disturbance,  and  possible  sep- 
sis; and  their  manifestations  will  present  no  more  radical 
differences  than  obtain  in  other  types  of  disease. 

In  illustration  of  those  cases  in  which  the  significance 
of  symptoms  has  not  been  demonstrated  by  a  later  inspec- 
tion of  pathogenic  lesions,  the  histories  of  a  certain  num- 
ber have  been  condensed  and  added  to  the  appended  series 
of  those  in  which  death  was  followed  by  necropsy.  These 
instances  have  been  selected  with  the  intent  of  showing 
with  recovery  all  the  symptoms  and  pathic  conditions  which 
in  another  class  have  been  connected  with  the  causative 
structural  alterations. 

Secondary  Inflammations. 
I.  Arachnitis. 
The  inflammatory  sequela  of  meningeal  contusion  is 
usually  known  as  meningitis  or  leptomeningitis.  The 
exception  suggested  in  the  previous  study  of  pathology 
to  the  ordinary  classification  of  intracranial  hemorrhages, 
that  the  terms  are  not  sufficiently  distinctive,  is  to  be  taken 
to  these  designations.     The  occasional  implication  of  the 


SYMPTOMATOLOGY. 


149 


dura  mater  in  a  suppurative  process  extending  from  a 
neglected  external  wound  through  a  cranial  fracture,  or 
its  farther  extension  to  the  deeper  structures,  constituting 
a  general  meningitis,  is  distinct  from  this  other  and  not 
always  infective  process  which  originates  in  the  parts  to 
which  it  is  confined ;  nor  is  this  a  dual  affection  of  the  pial 
and  arachnoid  membranes,  to  be  called,  for  some  fantastic 
reason,  leptoid,  but  a  simple  arachnoid  inflammation  or 
arachnitis.  Its  phenomena,  as  previously  explained,  are 
manifested  in  the  substance  of  the  pia  mater,  and  not  upon 
the  arachnoid  surface,  as  in  other  serous  inflammations, 
by  reason  of  an  exceptional  looseness  of  the  subserous  at- 
tachment. The  exudations  in  pleurisy  or  peritonitis  occur 
within  the  pleural  or  peritoneal  cavity,  rather  than  upon 
the  visceral  or  the  parietal  surface,  because  it  is  in  the  di- 
rection of  least  resistance. 

It  is  difficult  to  estimate  the  frequency  of  the  occur- 
rence of  traumatic  arachnitis.  There  are  many  instances 
in  which  some  localized  point  of  contusion  becomes  the 
seat  of  an  equally  limited  inflammation  which  can  have  no 
appreciable  influence  either  on  the  course  of  symptoms  or 
on  the  termination  of  the  case ;  and  there  are  many  others 
in  which  it  is  of  somewhat  larger  extent,  but  in  which  the 
influence  it  has  exerted  is  at  least  doubtful.  There  are 
others  still  in  which,  though  the  serous  effusion  is  abun- 
dant and  the  membrane  even  more  or  less  opaque,  the  fact 
that  death  came  before  the  establishment  of  reaction  nega- 
tives the  possibility  of  an  inflammatory  origin.  If  cases 
be  disregarded  in  which  the  existence  of  meningeal  in- 
flammation is  questionable  or  apparently  unimportant, 
there  are  but  eighteen  in  the  appended  general  series  in 
which  the  lesion  was  positive  and  at  the  same  time  suffi- 


150  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

ciently  extensive  to  be  influential  in  compassing  the  final 
result.  There  are  nine  in  which  the  effusion  was  purulent 
or  sero-purulent,  and  nine  in  which  it  was  sero-fibrinous. 
In  several  there  was  neither  external  wound  nor  cranial 
fracture.  They  are  too  few  in  number  for  wide  generaliza- 
tion in  symptomatology,  but  the  results  obtained  from 
their  analysis  are  so  generally  confirmed  by  comparison 
with  such  facts  as  may  be  gleaned  from  the  general  field 
of  traumatic  arachnitis  that  they  may  be  considered  typical. 
The  invasion  is  uncertain  as  to  time  and  character, 
and  the  subsequent  course  of  symptoms  is  irregular.  The 
antecedent  and  coexistent  lesions,  with  the  exception  of 
the  meningeal  contusion  upon  which  it  directly  depends, 
have  no  obvious  relation  to  the  development  of  the  in- 
flammatory process.  It  is  probable  that  infection  when 
it  occurs  will  be  early,  but  not  of  necessity  primary;  and 
that  non-infective  cases  will  be  oftener  late,  and  in  the 
usual  course  of  idiopathic  secondary  serous  inflammations 
in  prolonged  disease,  with  the  added  predisposition  derived 
from  the  antecedent  contusion.  The  invasion  of  a  trau- 
matic arachnitis  is  often  immediate  and  is  sometimes  de- 
ferred till  the  third  or  fourth  week,  but  is  more  frequent 
from  the  second  to  the  fourteenth  days.  The  initial  symp- 
toms, when  the  inflammation  is  of  low  grade,  are  occasion- 
ally so  insidious  as  to  fail  of  recognition,  but  in  general 
are  sharply  defined.  In  the  larger  number  of  cases,  those 
■which  may  be  considered  typical,  the  course  of  symptoms 
referable  to  antecedent  and  complicating  lesions  is  inter- 
rupted by  a  distinct  and  somewhat  sudden  rise  in  tempera- 
ture, accompanied  by  an  evident  change  in  the  general 
condition  of  the  patient,  who  becomes  irritable,  restless, 
delirious,   or  somnolent.     Active  delirium,   when  not  al- 


SYMPTOMATOLOGY.  151 

ready  existent  as  the  result  of  cerebral  contusion,  is  usu- 
ally the  first  general  manifestation  of  the  access  of  menin- 
geal inflammation.  The  occurrence  of  an  invasive  chill  is 
exceptional,  and  when  it  occurs  it  is  not  necessarily  indica- 
tive of  an  effusion  of  purulent  character.  The  subsequent 
course  of  temperature  is  erratic.  It  is  often  marked  by 
irregular  variations  from  day  to  day  and  from  hour  to 
hour,  not  usual  in  case  of  other  intracranial  lesions.  The 
irregularity  and  extent  of  the  thermal  changes,  which  may 
exceed  4°  within  each  twenty-four  hours,  are  characteristic. 
The  dependence  of  these  fluctuations  upon  a  secondary 
implication  of  thermotaxic  centres  situated  in  the  cerebral 
cortex,  as  has  been  suggested,  may  be  worthy  of  considera- 
tion when  the  existence  of  such  centres  has  been  better 
established.  In  rapidly  progressive  cases  of  marked  in- 
tensity, the  recessions  do  not  occur.  The  rise  in  tempera- 
ture which  indicates  the  supervention  of  an  arachnitis  in 
a  case  of  intracranial  injury  is  usually  distinct  and  some- 
times abrupt,  it  may  be  to  the  extent  of  4°  or  5°  or  even 
6°  in  a  few  hours.  The  average  temperature,  notwith- 
standing its  recessions,  is  afterward  high,  attaining  eleva- 
tions of  103°  to  107°-!-  and  in  articulo  mortis  ranging  from 
io5°-|-  to  109°.  The  association  of  other  grave  structural 
alterations  is  so  constant  that  it  is  difficult  to  demonstrate 
the  exact  relations  of  temperature,  but  the  sudden  primary 
rise  is  unmistakable,  and  the  observation  of  both  fatal  and 
recovering  cases  in  which  minimum  complications  existed 
has  made  the  subsequent  range  and  the  often  character- 
istic irregular  variations  sufficiently  well  assured.  The 
occasional  excessive  final  temperature  is  probably  always 
to  be  ascribed,  at  least  in  part,  to  concomitant  laceration. 
After  the  invasion,  and  aside  from  peculiarities  of  tern- 


152  INJURIES    OF    THE    BRAIN   AND    MEMBRANES. 

perature,  the  progress  of  the  disease  is  especially  char- 
acterized by  continued  manifestations  of  cortical  irritation. 
Some  grade  of  delirium  persists  in  almost  every  case,  and 
restlessness,  irritability,  or  extreme  sensitiveness  to  ex- 
ternal impressions  is  often  marked  long  after  consciousness 
has  been  finally  lost.  General  or  post-cervical  muscular 
rigidity,  muscular  twitching,  limited  or  slight  general  con- 
vulsive movements,  are  further  indications  of  nervous  ex- 
citation. The  occurrence  of  chill,  which  is  an  unusual 
invasive  symptom,  is  not  frequent  at  a  later  period.  Head- 
ache is  always  in  evidence,  w^hen  the  mental  condition  of 
the  patient  wnll  permit  its  recognition.  Additional  symp- 
toms have  little  value.  The  pupils  are  oftener  normal 
than  otherwise,  and  the  pulse  and  respiration  fail  to  reflect 
in  the  larger  proportion  of  cases  the  existing  inflammatory 
process.  In  many  instances  the  want  of  correspondence 
between  the  pulse  or  respiration  and  the  temperature  may 
be  ascribed  to  the  influence  of  complicating  lesions,  but  it 
is  equally  observed  in  others  in  which  only  a  moderate 
cerebral  contusion  and  no  laceration  exist,  and  in  which 
the  inflammation  is  of  the  highest  grade.  It  cannot  be 
said  that  in  a  majority  of  cases  there  is  any  sharp  contrast 
in  symptoms  which  indicates  the  character  of  the  effusion. 
A  copious  purulent  formation  may  be  indicated  by  high 
pulse  and  temperature  and  active  delirium  without  an  in- 
vasive chill,  or  may  be  preceded  by  a  chill  and  accompanied 
by  asthenic  symptoms ;  it  may  be  insidious  in  its  progress, 
as  an  essentially  serous  effusion  may  be  distinctly  evident 
and  of  easy  recognition.  In  a  minor  number  of  cases  the 
symptoms  are  commensurate  with  the  character  of  the  in- 
flammation. The  duration  of  the  disease,  like  its  period  of 
invasion,  is  uncertain,  and  may  be  for  days  or  weeks.     Its 


SYMPTOMATOLOGY.  1 53 

termination,  when  fatal,  is  in  asthenia  rather  than  in  coma 
as  the  result  of  pressure. 

It  is  unfortunate  that  the  greater  number  of  the  cases  of 
traumatic  arachnitis  which  have  been  reported  fail  in  the 
detail  essential  to  useful  generalization.  It  has  been  pos- 
sible, however,  to  supplement  the  eighteen  cases  included 
in  the  appended  series  of  intracranial  lesions  by  another 
collection  of  eight  heretofore  unpublished  cases,  all  of 
purulent  and  infective  character,  though  not  all  of  trau- 
matic origin.  These  exhibit  the  same  irregular  fluctua- 
tions of  temperature  and  varied  manifestations  of  cortical 
irritation  which  have  been  described.  The  results  which 
have  been  obtained  from  the  aggregation  of  the  two  series 
afford  sufficient  evidence  to  warrant  the  conclusion  that 
these  peculiarities,  together  with  a  more  or  less  decided 
change  in  symptomatology  at  its  inception,  indicate  the 
intercurrence  of  arachnoid  inflammation  in  a  case  of  in- 
tracranial injuy. 

2.   Abscess. 

Intracranial  or  cerebral  abscess  has  been  described  as 
of  two  varieties,  as  it  occurs  upon  the  surface  or  deep  in 
the  substance  of  the  brain.  The  lirst,  which  follows 
neglected  compound  fracture,  may  be  properly  excluded 
from  consideration.  It  affords  no  question  of  diagnosis, 
since  the  pyogenic  process  involves  alike  the  cerebral  sur- 
face, the  membranes,  and  the  cutaneous  wound;  and  if 
not  open  to  direct  visual  inspection,  or  manifest  through 
the  existence  of  a  fistulous  canal,  it  will  be  necessarily 
disclosed  in  the  exploration  of  the  infected  external  parts. 
It  is  an  almost  impossible  condition  when  the  wound  has 
received    sufficiently   early   and   intelligent   aseptic  care. 


154  INJURIES    OP    THE    BRAIN   AND    MEMBRANES. 

In  the  great  majority  of  cases  in  which  abscess  is  encoun- 
tered by  the  surgeon  it  has  received  no  previous  attention 
by  reason  of  the  stupidity  of  the  patient  and  his  friends, 
who  in  the  absence  of  primary  general  symptoms  have  re- 
garded the  injury  as  trivial.  The  concurrent  evidence  of 
local  and  systemic  infection  clearly  indicates  the  nature  of 
the  complication. 

The  history  of  traumatic  suppurative  inflammation  of 
the  deeper  portions  of  the  cerebral  parenchyma  is  not  only 
relatively  but  absolutely  difficult  to  trace.  There  are  no 
positive  external  indications,  and  no  pathognomonic  symp- 
toms. The  initial  symptoms  are  lost  in  those  of  the  pri- 
-mary  lesions,  which  it  complicates  as  well  as  follows,  and 
those  of  later  development  may  be  equally  impossible  of 
segregation  and  correct  interpretation.  Such  abscesses, 
which  have  existed  for  months  and  have  attained  large 
size,  have  often  escaped  recognition,  even  by  diagnosticians 
skilled  in  the  knowledge  of  intracranial  disease.  The 
idiopathic  cases,  which  have  been  made  typical,  present 
fewer  difficulties,  since  they  ordinarily  originate  in  a  single 
well-defined  form  of  extracranial  disorder,  and  pursue 
their  course  uncomplicated  by  other  intracranial  affections. 
They  occur  from  traumatic  cause  with  scarcely  greater  fre- 
quency than  do  the  unavoidable  suppurations  involving  the 
cortical  surface,  and  are,  except  in  pistol-shot  cases,  seldom 
attributable  to  neglect.  The  infrequency  of  traumatic 
central  abscess  of  the  brain  is  exemplified  in  the  appended 
series  of  five  hundred  cases,  in  which  it  occcurs  but  four 
times;  twice  in  the  frontal,  once  in  the  fronto-parietal,  and 
once  in  the  parieto-occipital  region ;  only  one  of  these  at- 
tained a  considerable  size.  It  has  been  of  most  frequent 
occurrence  in  connection  with  pistol-shot  wounds,  in  which 


SYMPTOMATOLOGY.  155 

an  ultraconservative  treatment  has  been  adopted.  In  one 
hundred  and  twelve  cases  reported  in  English,  Colonial, 
and  American  journals,  from  1879  to  1895,  mainly  treated 
without  effort  to  remove  the  bullet  or  fragments  of  bone 
which  penetrated  the  brain,  and  often  even  without  their 
removal  from  the  external  wound,  central  abscess  resulted 
in  eleven  cases,  or  nearly  ten  per  cent.,  in  addition  to 
many  purulent  infections  of  the  cerebral  surface.  The  his- 
tories of  abscesses  formed  in  this  way  should  be  of  great 
value  in  the  study  of  symptomatology  from  the  uniformity 
of  the  antecedent  lesion  and  from  the  absence  of  other 
complication,  but  inaccuracy  of  observation  and  careless- 
ness of  record  have  very  generally  minimized  their  im- 
portance. 

The  moment  at  which  the  inflammatory  process  begins 
in  the  contused  cerebral  tissue  is  impossible  even  ap- 
proximately to  determine.  As  purulent  infection  of  the 
normal  parenchyma  from  pneumonia  and  other  distant  in- 
fective diseases  may  remain  unsuspected  until  long  after 
the  pus  accumulation  has  become  large,  it  is  not  to  be  sup- 
posed that  its  very  beginning  will  be  always  or  even  usu- 
ally manifest  when  the  part  is  already  damaged  and  the 
lesion  indicated  by  perhaps  multifarious  and  to  some  ex- 
tent similar  symptoms.  In  the  most  frequent  form  of 
cerebral  abscess,  that  from  otitis  media,  in  which  the  ex- 
tension of  inflammation  is  perhaps  abrupt  and  the  previous 
symptoms  have  been  local  and  not  of  a  nature  to  obscure 
thoise  which  supervene,  it  is  possible  to  have  a  recogniza- 
ble initiatory  stage.  Pain  of  an  altered  character,  rigors, 
vomiting,  and  a  distinct  elevation  of  temperature  may 
unquestionably  mark  the  access  of  a  secondary  process 
within  the  cranium.     In  traumatic  cases  the  sudden  acces- 


156  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

sion  of  new  symptoms  may  be  followed  by  death  and  the 
post-mortem  discovery  of  cerebral  abscess;  but  they  will 
probably  indicate  some  crisis  in  its  progress,  some  in- 
cidental cerebral  or  meningeal  change,  some  increase  in  its 
size  which  has  made  it  no  longer  tolerable,  and  not  the 
inception  of  the  pyogenic  process.  The  existence  of 
exceptional  instances  must  be  admitted.  Thus,  in  one 
of  the  four  appended  cases,  the  pus  formation  was  at- 
tended by  distinctive  symptoms  in  its  incipience,  which 
were  recognized,  and  the  abscess  was  evacuated  at  a 
very  early  stage.  There  are  doubtless  invasive  symptoms 
in  every  case,  though  impossible  of  recognition — an 
elevation  of  temperature  included  in  that  of  the  an- 
tecedent contusion ;  pain,  which  is  masked  by  the  continued 
stupor  or  delirium  of  the  patient ;  or  circulatory  and  respira- 
tory derangements  which  are  equally  inappreciable  in  the 
existent  general  disorder  of  the  system.  It  may  be  as- 
sumed that  retrogressive  changes  begin  in  the  contused  or 
wounded  cerebral  tissue  immediately  after  the  occurrence 
of  injury,  and  that  with  or  without  the  invasion  of  an  in- 
fective organism,  at  a  variable  period,  at  once  or  soon  after- 
ward, they  are  followed  by  those  of  a  pyogenic  character. 
If  the  pyogenetic  action  is  intense  and  the  cumulation  of 
pus  is  rapid,  its  symptoms  are  at  once  evident,  despite  the 
continuance  of  those  of  the  primitive  lesions;  if  the  in- 
flammation is  of  low  grade  and  the  pus  formation  slow, 
the  presence  of  abscess  may  be  indicated  only  at  a  much 
later  period,  possibly  long  after  the  disappearance  of  the 
primary  symptoms. 

At  some  period,  early  or  late,  the  continued  growth  of 
the  abscess,  and  its  interference  with  the  nutrition  or  func- 
tion of  surrounding  parts,  will  usually  occasion  recogniz- 


SYMPTOMATOLOGY.  1 57 

able  symptoms,  whicli  may  be  characterized  as  general, 
and  as  localizing  or  dependent  upon  disturbance  of  special 
centres  of  control.  They  are  neither  numerous  nor  indi- 
vidually distinctive. 

The  occurrence  of  chill  or  rigors,  which  is  regarded  by 
Macewen  as  one  of  the  most  constant  of  early  symptoms  in 
the  idiopathic  cases  which  he  describes,  is  less  frequent  in 
the  traumatic  form.  The  fact  that  the  arachnoid  mem- 
brane is  not  implicated,  the  usually  lower  grade  of  inflam- 
mation, and  the  different  constitutional  and  nervous  con- 
dition of  the  patient,  may  serve  to  explain  this  distinction. 

The  temperature,  as  is  usual  in  cerebral  lesions,  is  of 
importance.  In  general,  it  is  elevated  during  the  pri- 
mary period  in  w^hich  the  symptoms  of  the  antecedent  con- 
dition predominate,  normal  during  a  subsequent  interval 
of  quiescence,  and  normal  or  subnormal  after  the  develop- 
ment of  the  abscess  has  been  sufficient  to  occasion  direct 
manifestations  of  its  existence.  This  generalization  is  by 
no  means  absolute.  In  those  cases  in  which  progress  is 
rapid,  and  the  pyogenic  process  begins  before  the  subsi- 
dence of  the  disturbance  occasioned  by  the  primitive  cere- 
bral lesion,  the  temperature  will  remain  continuously  high 
till  the  end;  the  sudden  onset  of  late  symptoms  may  be 
attended  by  an  elevation  from  normal  to  102°  or  103° ;  and 
even  in  the  more  insidious  cases  a  temperature  of  ioo°-|- 
is  not  an  extraordinary  occurrence.  After  operative 
evacuation  of  the  abscess  cavity,  an  immediate  and  signal 
advance  occurs,  which  is  soon  folloAved  by  a  recession  to  a 
point  but  little  above  the  normal  standard. 

Some  degree  of  pain  in  the  head  is  an  almost  constant 
symptom.  If  it  occurs  early  in  the  case,  it  is  indistinguish- 
able from  that  which  attends  contusion ;  at  a  later  period, 


158  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

especially  when,  after  an  interval  comparatively  devoid  of 
morbid  indications,  it  is  an  incident  in  the  inception  of  new 
symptoms,  it  becomes  characteristic.  It  may  then  recur 
suddenly  and  with  great  intensity,  or,  in  the  more  insidi- 
ous cases,  with  less  severity,  it  may  be  of  remarkable  per- 
sistency. It  is  oftener  in  the  frontal  region  than  elsewhere, 
even  in  the  case  of  cerebellar  abscess;  and,  when  the 
mental  condition  of  the  patient  permits,  it  may  be  aggra- 
vated or  even  detected,  though  otherwise  inappreciable,  by 
percussion ;  but  only  if  made  upon  the  corresponding  side 
(Mace  wen). 

The  pulse  is  characteristically  slow,  as  it  is  in  other 
lesions  of  the  cerebral  substance — not  much  above  or  be- 
low 60  in  the  greater  number  of  cases,  occasionally  even 
slower,  and  in  a  minority  of  cases  moderately  accelerated. 
After  evacuation  of  the  abscess  it  increases  in  frequency 
with  the  rise  in  temperature,  and  also  near  a  fatal  termi- 
nation. 

The  respiration,  like  the  pulse,  is  diminished  in  fre- 
quency and  like  the  pulse  condition  represents  a  usual  effect 
of  uncomplicated  cerebral  lesion.  It  is  also  at  times  irreg- 
ular, with  intervals  of  retardation  and  acceleration,  or  late 
in  the  progress  of  the  disease  may  have  the  Cheyne-Stokes 
peculiarities.  Thus  neither  the  pulse  nor  the  respiration 
reflects  the  special  character  of  the  structural  alteration. 

The  mental  condition,  again,  is  characteristic  but  not 
peculiar.  It  is  indistinguishable  from  that  which  often  re- 
sults from  cerebral  laceration,  and  sometimes  from  con- 
tusion, in  which  the  activity  of  cerebral  function  is  les- 
sened. There  are  apathy,  slowness  and  dulness  of  the 
mental  faculties,  insensibility  to  pain,  somnolence,  and  in- 
creasing stupor.     In  the  cases  in  which  the  pus  formation 


SYMPTOMATOLOGY.  1 59 

immediately  succeeds  the  primary  contusion  and  its  ad- 
vance is  rapid,  these  evidences  of  decadence  may  be  re- 
placed or  preceded  by  restlessness,  irritability,  and  delir- 
ium, which  terminate  as  before  in  stupor  and  coma. 

Prostration  and  emaciation  are  disproportionate  to  the 
amount  of  febrile  action  as  indicated  by  the  pulse  and 
temperature,  and  are  excessive  in  relation  to  other  atten- 
dant symptoms. 

Vomiting  or  vertigo  may  be,  either  one,  a  prominent  in- 
cident in  individual  cases,  and,  though  they  are  not  specific 
symptoms  in  abscess  formation  generally,  are  undoubtedly 
very  significant  in  the  particular  instances  in  which  they 
occur. 

Convulsions  and  muscular  rigidity  are  of  more  frequent 
occurrence,  and  the  suppurative  process  is  then  so  generally 
located  in  the  temporal  or  frontal  lobe  that  they  may  be 
regarded  as  in  some  degree  localizing  symptoms. 

Constipation  is  in  no  sense  an  indication  of  suppuration, 
but  is  common  to  many  morbid  cerebral  conditions ;  and 
retention  of  urine  when  it  exists  is  to  be  in  no  greater  de- 
gree attributed  to  the  special  character  of  the  lesion.  The 
loss  of  faecal  and  urinary  control  in  the  terminal  stage 
signifies  only  the  destructive  character  of  the  lesion . 

An  enlargement  of  the  posterior  cervical  glands  after 
the  cicatrization  of  an  external  wound  in  one  of  the  ap- 
pended cases,  and  before  the  occurrence  of  symptoms  of  an 
abscess  beneath  the  angular  gyrus,  attracted  attention.  It 
is  possible  that  further  observation  may  show  this  condi- 
tion to  have  some  symptomatic  importance. 

The  second  class  of  symptoms  depends  upon  the  direct 
or  indirect  implication  of  cerebral  centres  of  control.  In 
eleven  of  an  accessible  series  of  twenty  traumatic  abscesses, 


l6o  INJURIES    OF    THE    BRAIN   AND    MEMBRANES. 

motor  paralysis,  anaesthesia,  aphasia,  disturbed  reflexes, 
optic  neuritis,  hemianopsia,  or  abnormal  conditions  of  the 
pupils,  singly  or  in  combination,  were  observed.  The  fact 
that  nutritive  disturbances  extend  for  a  considerable  dis- 
tance from  the  abscess  formation  lessens  the  significance  of 
these  functional  or  other  disorders  in  localizing  its  situa- 
tion ;  but  they  still  have  an  approximate  value.  In  con- 
nection with  other  and  more  general  symptoms,  they  have 
great  corroborative  diagnostic  importance.  The  paralyses 
are  of  most  frequent  occurrence,  since  the  abscess  is  in  the 
larger  proportion  of  cases  situated  in  the  frontal  or  tem- 
poral lobe  in  the  vicinity  of  the  motor  areas,  and  for  the 
same  reason  the  reflexes  are  often  exaggerated  or  dimin- 
ished. These  functional  disorders,  together  with  aphasia 
and  anaesthesia  as  results  of  local  pressure  or  of  adjacent 
structural  alterations,  invite  no  special  comment.  The 
existence  of  a  lateral  hemianopsia  in  like  manner  may 
result  from  the  implication  of  a  visual  area  in  the 
event  of  an  abscess  occurring  in  the  parieto-occipital 
region. 

Pupillary  phenomena  are  not  infrequently  manifest 
when  abscess  is  seated  in  the  temporo- sphenoidal  or  frontal 
lobe.  The  pupil  on  the  corresponding  side  is  then  either 
myotic  or  mydriatic,  with  some  degree  of  fixation,  as  the 
abscess  is  small  and  causes  iritation,  or  as  it  is  large  and 
exercises  pressure.  ^lyosis  may  give  place  to  mydriasis  as 
a  small  abscess  increases  in  bulk.  Occasionally  the  only 
pupillary  change  is  the  sluggishness  of  one  pupil  to  both 
light  and  accommodation.  If  the  abscess  is  large,  the  pres- 
sure upon  the  third  nerve,  which  occasions  mydriasis,  may 
at  the  same  time  cause  ptosis  and  external  strabismus 
(Macewen). 


SYMPTOMATOLOGY.  l6l 

The  occurrence  of  an  optic  neuritis  after  an  abscess  has 
attained  moderate  size  is  not  infrequent,  and  while  it  is  a 
local  manifestation,  so  far  as  it  is  a  consecutive  disease  of 
a  special  part,  it  is  not  a  localizing  indication,  and  might 
perhaps  have  been  more  properly  included  in  the  enumera- 
tion of  general  symptoms.  It  is  due  to  an  increase  of  in- 
tracranial pressure  without  reference  to  the  site  of  the 
abscess,  and  is  the  most  characteristic  of  all  the  abscess 
symptoms,  in  the  sense  that  it  is  occasioned  by  a  smaller 
number  of  lesions  than  any  other.  It  may  exist  upon  one 
side  or  both ;  when  double  it  will  not  always  be  of  greatest 
extent  upon  the  corresponding  side,  and  when  single 
may  be  of  the  opposite  nerve.  The  atrophic  stage  is 
seldom  reached  before  the  culmination  of  the  primary 
disease. 

Analytical  examination  and  enumeration  of  these 
varied  possible  symptoms  are  easier  than  their  synthetical 
rearrangement  to  form  a  typical  case.  It  may  be  said 
that  while  in  the  greater  number  of  instances  the  pyogenic 
process  may  be  continuous  with  the  degenerative  changes 
which  immediately  follow  the  primary  cerebral  contusion, 
there  will  be  an  interval  in  which  the  progress  of  symp- 
toms is  unnoted.  This  is  neither  a  period  of  incubation 
nor  of  intermission,  but  of  remission,  during  which  it  is 
not  unusual  for  the  patient  to  follow  his  ordinary  voca- 
tions, and  if  unobservant  of  himself  to  be  unaware  that  he 
is  really  ill.  This  interval  may  extend  over  many  months, 
but  in  time,  suddenly  or  insidiously,  more  urgent  symp- 
toms will  be  developed;  either  an  intense  pain  in  the  head, 
vomiting,  and  vertigo,  or  a  convulsion,  or  muscular  rigidity, 
with  great  prostration,  followed  by  stupor  and  coma,  may 
precede  an  early  fatal  termination ;  or  pain  persistent  rather 


l62  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

than  severe,  gradual  prostration  and  comparatively  rapid 
emaciation,  with  slow  pulse  and  respiration  and  possibly 
a  slightly  subnormal  temperature,  slowly  failing  sight, 
mental  and  physical  lethargy,  increasing  somnolence  and 
stupor  lapsing  into  final  coma,  may  extend  over  many 
days  or  even  weeks.  Intercurrent  muscular  weakness  or 
paralysis,  anaesthesia,  aphasia,  or  pupillary  changes  may 
emphasize  its  progress.  It  often  happens  that  many  of 
these  symptoms  are  wanting,  and  that  others  are  indefinite 
or  but  faintly  suggestive  of  the  nature  of  the  cerebral  lesion. 
The  usual  end  of  all  cases,  whether  their  indications  have 
been  decisive  or  obscure,  is  death  from  coma  in  a  previ- 
ously existent  asthenic  condition.  In  the  comparatively 
few  instances  in  which  abscess  is  acute,  suppuration  is  dif- 
fuse and  pya^mic  infection  follows;  in  the  vast  majority 
of  chronic  abscesses,  capsulation  is  an  efficient  protection 
from  rupture  and  a  consequent  diffuse  infective  inflamma- 
tion. It  is  possible  that  the  capsule  may  give  way,  and 
the  pus  reach  the  cerebral  surface,  or  that  it  may  break 
through  into  the  ventricles,  but  these  terminations,  if  they 
occur  at  all,  must  be  of  great  infrequency.  There  is 
more  probability  that  an  extension  of  the  inflammatory 
area  about  the  abscess  will  involve  the  arachnoid  mem- 
brane. If  an  atachnitis  supervenes,  either  from  rupture  of 
the  abscess  and  an  access  of  pus  to  the  cerebral  surface, 
or  from  simple  extension  of  the  peripheral  inflammation, 
there  will  be  sudden  increase  in  the  severity  and  urgency 
of  symptoms ;  there  will  be  an  abrupt  rise  in  temperature, 
rapid  pulse,  hurried  respiration,  and  other  indications  of 
the  new  pathic  condition.  In  the  event  of  a  purulent  in- 
vasion of  the  ventricles,  the  transition  of  symptoms  will 
be  still   more    violent,    and   with   even    less    premonition. 


SYMPTOMATOLOGY.  163 

The  face  becomes  livid,  the  pupils  are  widely  dilated,  the 
respiration  is  insufficient  and  perhaps  stertorous,  the  pulse 
frequent  and  oppressed,  and  the  temperature  greatly  ex- 
alted; the  muscles  are  convulsed,  coma  is  immediate,  and 
death  soon  ensues. 


Chapter    IV. 


DIAGNOSIS. 

DIRECT   LESIONS. 

The  differential  diagnosis  of  intracranial  lesions  is 
usually  practicable  if  symptoms  are  accurately  noted  and 
are  subjected  to  careful  analysis.  They  are  first  to  be  dis- 
tinguished from  all  other  morbid  conditions,  especially 
from  those  involving  loss  of  consciousness  or  delirium,  and, 
secondly,  they  are  to  be  discriminated  from  each  other. 
The  existence  of  an  encephalic  injury  is  often  patent  from 
numerous  and  manifest  indications,  and  from  a  knowledge 
of  the  immediate  history  of  a  case ;  but  its  recognition 
when  symptoms  are  obscure  or  perhaps  mainly  negative, 
and  no  historical  data  are  attainable,  may  require  the  exer- 
cise of  great  circumspection  and  exact  discrimination.  The 
frequent  instances  in  which,  after  a  survival  of  the  patient 
for  many  days,  extensive  cerebral  wounds  are  unsuspected 
till  disclosed  upon  necropsic  examination,  evince  the  ne- 
cessity of  care,  if  not  the  difficulty  in  diagnosis  which  may 
be  encountered.  The  case  of  an  unknown  man  found  un- 
conscious in  the  street,  taken  to  a  hospital,  retained  in  a 
medical  ward,  and  first  discovered  in  the  dead-house  to 
have  been  the  victim  of  accident  or  violence,  is  not  excep- 
tional. 

The  primary  symptom  which  undoubtedly  overshadows 
all  others,  in  all  forms  of  intracranial  injur}',  is  coma  or 
some  decree  of  unconsciousness,  which  at  the  same  time  is 


DIAGNOSIS.  165 

the  most  striking  symptom  in  various  other  morbid  condi- 
tions. It  is  natural  that  this  identity  should  be,  as  it  is, 
the  most  fruitful  source  of  error  in  diagnosis.  The  num- 
ber of  idiopathic  diseases  in  which  coma  is  characteristic  is 
large,  possibly  twenty  and  more.  In  case  of  the  greater 
part  of  these,  as  in  malignant  fever,  facial  erysipelas,  or 
diabetes,  the  danger  of  confusion  with  the  effects  of  trau- 
matism is  too  remote  to  necessitate  any  reference  to  their 
distinctive  signs;  in  others,  as  in  epilepsy  or  sunstroke, 
the  distinction  is  so  readily  made  that  their  consideration 
may  be  omitted  with  equal  propriety;  but  in  apoplexy, 
uraemia,  alcoholism,  and  opium  narcosis  diagnostic  dif- 
ficulties are  sometimes  so  great  and  erroneous  conclusions 
so  often  reached  as  to  demand  some  comparison  of  their 
symptoms  with  those  which  follow  intracranial  traumatism. 
The  occurrence  of  delirium,  which  sometimes  replaces  or 
accompanies  the  coma  of  alcoholism  or  of  uraemia,  may  be  a 
special  source  of  embarrassment  when  these  diseases  are 
brought  in  question. 

In  the  coma  of  opium  poisoning  the  pupils  are  strongly, 
immovably,  and  symmetrically  contracted ;  the  face,  at  first 
pale,  becomes  swollen,  flushed,  and  livid;  the  breath  may 
have  the  odor  of  opium ;  the  skin  is  warm  and  moist  or 
perspiring;  the  patient  can  be  aroused,  and  the  mental 
condition  is  then  found  to  be  normal  and  the  articulation 
unaffected ;  the  repsiration  is  markedly  and  progressively 
diminished  in  frequency,  and  is  slow,  it  may  be  with 
stertor,  and  with  a  pause  between  inspiration  and  expira- 
tion; the  pulse  is  at  first  slow  and  full,  and  later  is  feeble 
and  rapid;  the  temperature  is  slightly  subnormal;  and  the 
reflexes  are  absent  without  the  occurrence  of  other  disorders 
of  muscular  function. 


l66  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

In  urasmic  coma  the  pupils  are  dilated,  and  sluggish  or 
irresponsive  to  light;  the  face  is  white,  and  the  surface 
cedematous;  the  breath  has  a  sweetish  odor;  the  patient 
can  rarely  be  aroused;  the  respiration  is  frequent  and 
irregular,  the  inspiration  hissing  and  the  expiration  some- 
times noisy;  the  pulse  is  irregular,  incompressible,  and 
usually  rapid;  the  temperature  is  normal,  the  muscular 
function  and  reflexes  are  unaffected,  and  the  urine  is 
albuminous. 

In  apoplexy  the  pupils  are  dilated,  except  in  hemor- 
rhage into  the  pons,  and  are  immovable;  the  eyes  are 
glassy  and  there  may  be  strabismus ;  the  face  is  pale  or 
darkly  flushed,  the  surface  is  cold  and  moist,  the  odor  of 
the  breath  is  natural,  the  patient  cannot  be  aroused;  the 
respiration  is  slow,  irregular,  and  stertorous,  and  the  lips 
are  covered  with  frothy  saliva;  the  pulse  is  variable,  at 
first  small  and  infrequent,  and  later  full,  hard,  and  fre- 
quent; the  superficial  arteries  are  often  rigid;  the  tem- 
perature, at  first  subnormal,  becomes  and  remains  normal 
in  cases  destined  to  recovery,  but  in  those  which  are  fatal 
it  continues  to  rise  and  attains  a  high  degree ;  there  may 
be  unilateral  paralysis  of  the  face  or  extremities  with  ex- 
aggerated reflexes  on  the  paralyzed  side,  and  the  urine  is 
often  retained. 

In  acoholic  coma  the  pupils  are  not  characteristically 
changed,  and  are  usually  normal;  the  face  is  likely  to  be 
flushed,  and  the  surface  is  cold;  the  breath  is  alcoholic; 
the  patient  can  be  aroused  unless  coma  is  profound,  and 
he  is  then  irritable  and  incoherent,  and  the  articulation  is 
indistinct ;  the  respiration  is  regular  and  without  stertor, 
may  be  slow  or  hurried,  and  expiration  is  quickened ;  the 
pulse  is  frequent  and  weak,  but  becomes  slow  as  coma  in- 


DIAGNOSIS.  167 

creases ;  the  temperature  is  normal  in  some  instances,  but 
when  the  comatose  condition  is  profound  is  markedly  sub- 
normal ;  and  the  urine  may  contain  alcohol. 

The  symptoms  detailed  as  occurring  in  these  several 
forms  of  coma  are  variously  modified,  and  many  of  theni 
perhaps  absent  altogether,  in  individual  cases;  but  the 
picture  as  presented  is  representative  and  substantially 
correct. 

The  symptoms  occasioned  by  intracranial  lesions  have 
been  sufficiently  described ;  it  remains  to  indicate  their 
diagnostic  relations.  The  fact  of  some  intracranial  injury 
having  been  received  will  be  at  once  suggested  by  the  ex- 
istence of  wound  or  contusion  of  the  scalp  or  of  demon- 
strable fracture  of  the  cranium.  It  will  of  itself  establish 
the  diagnosis  in  a  large  majority  of  cases  in  which  the 
origin  of  coma  is  in  doubt,  since  the  instances  are  ex- 
ceptional in  which  the  extracranial  lesion  and  the  intra- 
cranial disorder  are  independent  of  each  other,  and  are 
scarcely  more  numerous  in  which  a  traumatic  intracranial 
lesion  is  not  attended  by  some  superficial  or  cranial  injury. 
It  is  possible  that  a  drunken  man,  or  an  epileptic,  or  one 
falling  in  an  apoplectic  attack,  should  wound  or  contuse 
his  scalp  or  fracture  his  skull,  either  with  or  without  receiv- 
ing further  cerebral  hurt,  and  that  subsequent  coma  or 
delirium,  which  might  be  fairly  attributable  either  to  the 
traumatism  or  to  the  antecedent  morbid  condition,  would 
be  difficult  of  interpretation.  The  immediate  history  of  a 
case,  if  attainable,  is  of  first  importance  in  establishing  a 
prima  facie  probability  of  the  presence  or  absence  of  en- 
cephalic lesion ;  but,  as  often  happens  when  patients  have 
been  found  unconscious  in  the  street,  the  positive  or  nega- 
tive evidence  derived  from  external  examination  must  take 


l68  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

its  place.  This  must  be  thorough  to  be  of  absolute  value; 
the  head  may  have  to  be  shaved  to  discover  contusions  or 
haematomata,  or  incision  made  to  permit  tactile  or  visual 
detection  of  linear  fracture ;  and  the  occurrence  of  pathog- 
nomonic external  hemorrhages  of  internal  origin  must  be 
recognized  and  appreciated.  Such  an  inspection  might  be 
sufficient  to  determine  the  probable  traumatic  or  idiopathic 
nature  of  an  initial  lesion,  but,  even  with  the  aid  of  an  ex- 
act history,  would  be  a  manifestly  unsafe  reliance  without 
the  confirmation  afforded  by  general  symptoms.  The  crit- 
ical study  of  the  various  features  of  a  case  will  ordinarily 
serve  to  determine  not  only  the  etiological  character  of  its 
lesions  but  also  the  occasional  coexistence  of  traumatism 
and  antecedent  disease.  In  this  scrutiny  the  symptomatic 
peculiarities  of  the  several  forms  of  coma  must  be  con- 
sidered and  contrasted,  or  reconciled  with  the  actual 
conditions  presented,  and  the  diagnosis  perhaps  finally 
established  by  the  predominant  importance  of  a  single 
symptom. 

The  disease  or  morbid  condition  with  which  intra- 
cranial injury  is  most  frequently  confounded  is  alcoholic 
coma.  It  is  scarcely  possible  to  overestimate  the  import- 
ance of  the  correct  differentiation  of  these  two  forms  of 
coma,  of  such  diverse  origin  and  significance.  Error  in 
diagnosis  not  only  inflicts  great  unnecessary  suffering,  ad- 
ditional danger,  and  possible  disgrace  upon  the  patient, 
but  places  corresponding  responsibility,  both  moral  and 
professional,  upon  the  surgeon.  The  number  of  instances 
in  which  the  indications  of  most  serious  intracranial  injury 
have  been  mistaken  for  the  results  of  simple  alcoholic  ex- 
cess is  inexcusably  great,  and  justifies  more  than  casual 
reference.       This   misconception    of    the    significance    of 


DIAGNOSIS.  169 

symptoms  is  even  oftener  the  result  of  negligence  tlian  of 
incompetence.  It  is  often  apparently  forgotten  that  while 
there  may  be  a  fair  presumption  that  a  man  found  uncon- 
scious in  the  street,  or  delirious  in  a  police  station,  is 
simply  drunk,  it  is  no  warrant  for  the  neglect  of  ordi- 
nary physical  examination  or  disregard  of  obvious  indica- 
tions. The  appended  .series  of  cases  includes  many  in 
which  fractured  skull  or  lacerated  brain,  plainly  evident 
when  suspected  and  sought,  has  been  unnoted  in  a  hastily 
formed  theory  of  alcoholic  coma;  others,  in  which  the 
patient  has  been  left  by  the  ambulance  surgeon  to  die  in 
the  police  cells,  or  sent  from  the  police  court  to  a  term  of 
imprisonment ;  and  very  many  in  which  he  has  been  de- 
tained in  the  alcoholic  wards  of  a  hospital  or  even  trans- 
ferred to  an  asylum  for  the  insane.  These  flagrant  scan- 
dals still  occur,  and  with  increased  discredit  to  hospital 
administration,  since  increased  experience  has  shown  the 
necessity  of  special  provisions  to  avert  the  possibility  of 
their  occurrence.  It  is  primarily  essential,  in  approaching 
the  diagnosis  of  a  case  of  apparent  aloholic  coma,  to  divest 
the  mind  of  all  preconceptions  and  to  realize  that  an  un- 
conscious man  with  a  scalp  wound  is  not  necessarily  drunk, 
and  that  even  a  drunken  man  may  be  so  seriously  injured 
as  to  require  hospital  treatment.  Unconsciousness  and  the 
existence  of  superficial  injury  of  the  head  should  in  any 
case  arrest  attention,  and  awaken  suspicion  of  brain  lesion. 
Coma  ought  not  to  be  ascribed  to  alcohol,  except  by  the 
strictest  process  of  exclusion.  Symptoms  which  are  most 
likely  to  characterize  different  forms  of  head  injury  should 
be  sought  seriatim,  and  their  absence,  not  less  than  their 
presence,  noted.  It  should  be  remembered,  finally,  that 
even  if  the  patient  be  intoxicated,  this  circumstance  should 


I/O  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

Strengthen  rather  than  allay  suspicion  of  traumatism.  It 
follows  that  the  flushed  face  and  sodden  features,  the  al- 
coholic breath,  which  mark  habitual  inebriety,  the  inco- 
herence and  thickened  articulation  when  the  patient  can 
be  aroused,  are  nothing  to  the  purpose  till  the  fact  of  cere- 
bral traumatism  has  been  excluded. 

The  observance  of  temperature  will  afford  an  almost 
absolute  means  of  diagnosis.  In  alcoholic  coma,  when 
profound,  the  temperature  is  subnormal,  often  not  above 
96°;  and  when  less  complete,  not  above  the  normal  stand- 
ard; its  depression  is  likely  to  be  proportionate  to  the 
depth  of  unconsciousness.  These  generalizations  are 
founded  upon  a  sufficient  number  of  observations  to  justify 
the  assumption  that  they  are  essentially  correct.  The 
rule  that  in  cases  of  intracranial  injury  the  temperature 
is  elevated  is  equally  positive,  and  when  the  lesion  is  sub- 
stantially cerebral,  the  one  in  which  the  general  condition 
most  closely  resembles  that  of  alcoholism,  the  contrast  in 
temperature  is  most  decided.  In  a  majority  of  instances 
in  which  cerebral  lesion  exists,  the  temperature  is  charac- 
teristic from  the  first,  but  in  a  certain  number  it  is  prima- 
rily depressed,  either  from  general  shock  or  from  the  fact 
of  a  concomitant  alcoholic  condition ;  and  in  this  event,  if 
other  symptoms  are  not  conclusive,  some  delay  must  oc- 
cur in  arriving  at  a  positive  opinion.  If  the  comatose 
condition  has  resulted  purely  from  alcoholic  excess,  the 
temperature  will  in  a  few  hours  become  normal  with  the  re- 
storation of  consciousness;  if  some  intracranial  injury  has 
coexisted,  the  temperature,  after  the  same  interval,  whether 
or  not  consciousness  is  regained,  will  rise  above  its  normal 
degree  to  an  extent  dependent  upon  the  nature  of  the 
lesion.     In  the  cases  in  which  primary  temperature  is  de- 


DIAGNOSIS.  171 

pressed  by  general  shock,  that  condition  will  be  recognized 
by  its  tis-iial  symptoms,  and  after  reaction  has  been  estab- 
lished the  elevation  of  temperature  will  be  no  less  char- 
aracteristic.  Even  if  intracranial  hemorrhage  has  been 
the  essential  lesion,  and  the  subsequent  range  of  tempera- 
ture is  less  than  in  cerebral  trauma,  it  is  still  distinctive. 

In  the  comparatively  exceptional  instances  of  primary 
subnormal  temperature,  in  connection  with  traumatic  in- 
tracranial lesions,  the  immediate  recognition  of  structural 
injury  is  ordinarily  practicable  from  an  examination  of  the 
other  symptoms  presented.  The  indications  of  alcoholic 
insensibility,  aside  from  those  of  inebriety,  are  mainly 
negative;  neither  the  pupils,  pulse,  nor  respiration,  are 
characteristic;  there  is  no  paralysis,  and  the  patient,  except 
in  extreme  cases,  can  be  aroused.  If  intracranial  lesion 
exists,  it  can  hardly  fail  that  some  one  or  more  of  its  dis- 
tinctive symptoms  can  be  detected — unequal  or  dilated 
pupils,  muscular  paralysis  or  rigidity,  unsymmetrical  radial 
pulsations  at  the  two  wrists,  abnormal  relation  of  pulse, 
respiration,  and  temperature,  or  some  other  positive  indica- 
tion of  organic  change,  which  will  be  manifest  while  tem- 
perature is  yet  depressed. 

The  active  delirium  which  may  occur  in  the  period  im- 
mediately succeeding  the  reception  of  a  brain  injury  is 
sometimes  very  difficult  to  distinguish  from  that  which  re- 
sults from  alcoholic  excess.  The  difficulty  may  be  further 
increased  by  the  fact  that  the  subject  is  of  known  intem- 
perate habits,  and  was  very  likely  intoxicated  when  first 
^brought  under  observation.  In  those  cases  in  which  de- 
lirium is  the  first  symptom  noted,  and  probably  replaces 
unconsciousness,  the  condition  is  made  very  deceptive. 
In  this  instance  we  are  not  aided  by  the  temperature,  which 


172  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

is  usually  elevated  in  alcoholic  delirium,  and  the  elevation 
may  be,  and  often  is,  very  great.  There  may  be  no  posi- 
tive means  by  which  such  a  case,  if  alcoholic,  can  be  diag- 
nosticated from  one  of  cerebral  contusion ;  but  few  cases  of 
laceration  will  be  encountered  in  which  at  least  one  or  two 
characteristic  symptoms  cannot  be  detected,  and  there  are 
differences  even  in  the  character  of  the  delirium  which 
may  be  recognized,  though  not  easily  formulated. 

In  the  differentiation  of  the  coma  of  apoplexy  from  that 
of  encephalic  injury  the  temperature  is  again  of  paramount 
importance.  The  observations  of  Bourneville,  confirmed 
by  others  of  more  recent  date,  show  that  in  apoplexy  the 
primary  temperature  is  subnormal,  and  that  it  subsequently 
rises  scarcely  above  the  normal  standard  except  when  death 
ensues.  In  an  accessible  series  of  twenty-three  cases,  with 
a  mortality  of  seven,  the  highest  temperature  in  twenty- 
one  was  ioo°-|-;  in  two,  which  were  fatal,  it  reached  102° 
-104°.  This  is  in  marked  contrast  to  what  happens  in 
cases  in  which  the  lesion  is  traumatic,  and  in  which  from 
a  possible  depression  the  rise  is  immediate,  whether  re- 
covery or  death  impends,  and  is  practically  continuous 
while  the  result  remains  in  abeyance.  The  distinctive 
peculiarities  of  temperature  in  alcoholism,  cerebral  trau- 
matism, and  apoplexy  are  thus  well  marked.  There  are 
no  other  individual  symptoms  in  apoplexy  which  are  in  any 
degree  pathognomonic,  or  which  may  not  be  reproduced 
from  a  traumatic  lesion ;  in  their  ensemble  they  may  ac- 
quire a  more  positive  diagnostic  value. 

It  may  happen  that  a  patient,  seized  with  an  attack  of 
cerebral  hemorrhage,  falls  and  suffers  a  consecutive  in- 
tracranial injury.  Two  such  instances  occur  in  the  ap- 
pended series  of  cases,  in  each  of  which  a  cerebellar  lac- 


DIAGNOSIS.  173 

eration  was  produced.  In  the  absence  of  history,  such  a 
concurrence  of  lesions  would  probably  be  impossible  of 
detection. 

The  diagnosis  of  traumatic  from  opium  or  ursemic 
coma  presents  fewer  difficulties.  In  the  second,  the 
strongly  contracted  pupils  and  excessively  slow  respira- 
tion, the  fact  that  when  unconsciousness  is  not  absolute 
the  patient  can  be  aroused  and  that  his  mental  condition  is 
then  clear,  the  often  swollen  and  livid  face,  and  perhaps 
the  odor  of  the  drug  upon  his  breath,  with  a  practically 
normal  temperature  and  the  absence  of  all  traumatic  in- 
dications, make  the  pathic  condition  clear.  In  the  third, 
the  facies,  general  symptoms  of  renal  disease,  and  albumi- 
nous urine,  even  without  the  contrast  of  the  special  expres- 
sions of  different  cerebral  lesions,  are  equally  convincing. 
The  only  probable  danger  of  confounding  either  one  of 
these  two  forms  of  coma  with  that  which  results  from  in- 
tracranial injury  will  arise  from  inattention  rather  than 
from  any  essential  difficulty  in  their  discrimination. 

These  questions  of  diagnosis,  as  it  concerns  different 
forms  of  coma,  have  been  considered  upon  the  supposition 
that  no  previous  history  of  a  case  is  attainable,  and  that 
the  fact  of  traumatism,  even,  is  unknown,  except  as  it 
may  be  indicated  by  some  discoverable  superficial  or 
cranial  lesion.  It  is  fortunate  that  the  immediate  ante- 
cedent circumstances  can  usually  be  learned;  and,  with 
symptoms  which  can  then  have  no  equivocal  meaning,  no 
doubt  need  remain  that  some  sort  of  intracranial  injury 
has  been  sustained. 

The  fact  that  an  intracranial  injury  has  been  received 
having  been  determined,  the  designation  of  the  special 
form  it   has   assumed   is  fraught  with  difficulties,  which 


174  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

sometimes  prove  insuperable.  The  lesions  are  likely  to 
be  multiple,  and  many  of  the  symptoms  to  be  equally  ref- 
erable to  either  one  of  their  number;  the  manifestations 
of  a  circumscribed  lesion  are  often  lost  in  those  of  one  of 
a  diffuse  character;  and  similar  results  constantly  ensue 
from  different  causes ;  but  a  diagnosis  of  sufficient  if  not 
absolute  exactitude  is  ordinarily  possible.  It  is  essen- 
tial to  determine  not  only  the  character  but  the  location  of 
a  lesion,  with  a  view  both  to  prognosis  and  to  possible 
operative  interference.  In  cases  which  are  obscure, 
diagnosis  must  rest  primarily  upon  the  recognition  of  in- 
dividual symptoms,  and  secondarily  upon  a  study  of  their 
relations  of  time  and  circumstance  and  upon  a  knowledge 
of  what  has  been  established  as  to  the  dependence  of  each 
upon  definite  structural  alterations.  Every  existent  symp- 
tom must  be  appreciated  and  estimated  in  a  quest  for  one 
which  is  either  pathognomonic  or  characteristic,  and  this, 
when  detected,  must  be  reconciled  with  others  apparently 
inconsistent,  though  it  may  necessitate  the  assumption  of 
multiple  rather  than  of  single  lesion.  The  method  of  de- 
velopment, not  less  than  the  existence  of  symptoms,  the 
period  of  their  occurrence,  and  the  changes  which  they 
suffer,  must  be  accurately  noted,  and  a  provisional  diag- 
nosis often  left  to  time  to  confirm  or  disprove. 

The  differentiation  of  the  several  primary  lesions  has 
been  already  indicated,  either  directly  or  by  implication, 
in  the  enumeration  and  delineation  of  individual  symptoms ; 
but  the  more  extended  study  of  comparative  symptoma- 
tology, in  which  the  modified  significance  of  the  external 
manifestations  of  these  internal  injuries  is  to  be  estimated 
in  view  of  their  period  of  development,  length  of  continu- 
ance, and  mutual  relations,  is  usually  requisite  to  either 


DIAGNOSIS.  175 

certainty  or  exactitude  of  diagnosis.  It  is  practicable  to 
make  the  consideration  of  specific  diagnostic  methods 
scarcely  more  than  suggestive ;  the  possible  variations  in 
the  nature  and  relation  of  coexisting  or  consecutive  symp- 
toms are  too  multitudinous  to  admit  of  systematic  or 
detailed  description  and  analysis. 

The  examination  which  may  be  instituted  to  determine 
the  character  of  an  intracranial  injury  naturally  begins  with 
the  condition  of  unconsciousness,  at  once  the  most  notable 
and  the  most  constant  of  all  primary  symptoms.  If  by 
chance  consciousness  has  been  retained,  inquiry  will  then 
be  at  first  directed  to  the  proper  interpretation  in  the  light 
of  attendant  conditions  of  whatever  other  symptom  may 
be  most  prominent.  The  loss  of  consciousness  which  im- 
mediately succeeds  a  cephalic  injury  is  always  the  result 
of  diffuse  cerebral  contusion;  if  unconsciousness  is  pre- 
ceded by  a  conscious  interval,  however  brief,  or  if  after 
restoration  of  consciousness  its  privation  recurs,  it  is  occa- 
sioned by  some  form  of  intracranial  hemorrhage.  These 
distinctions  are  theoretically  simple,  and  in  practice  readily 
made.  If,  however,  primary  unconsciousness  is  permanent 
or  greatly  prolonged,  its  continuance  may  be  due  either  to 
the  severity  of  cerebral  lesion  or  to  a  complicating  hemor- 
rhage ;  and  whether  the  one  has  persisted  from  the  begin- 
ning or  has  been  at  any  time  replaced  by  the  other,  or 
whether  both  exist  together,  can  be  determined,  if  at  all, 
only  by  a  study  of  all  the  symptoms  presented.  The 
pulse,  temperature,  and  respiration  must  be  systematically 
recorded  in  every  case  from  the  first  opportunity  afforded 
for  observation  until  its  end,  and  the  accuracy  of  this  rec- 
ord, not  only  from  day  to  day,  but  sometimes  from  hour 
to  hour,  may  be  of  the  utmost  diagnostic  importance ;  of 


176  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

these,  the  temperature  in  its  course  and  variations  will 
afford  in  the  greater  number  of  cases  the  most  distinctive 
indication  of  the  nature  of  the  lesion. 

The  primary  temperature  is  above  the  normal  standard 
in  all  forms  of  intracranial  lesion,  when  it  has  not  been 
depressed  by  general  shock  or  the  effect  of  alcoholic  ex- 
cess. In  cases  of  comparativel}'  uncomplicated  hemor- 
rhage, it  will  range  from  98.5°  to  99.5°,  and  will  not  sub- 
sequently exceed  100°,  unless  general  cerebral  contusion 
is  well  pronounced,  when  it  may  reach  101°  or  even  ioi°-|-. 
If  the  essential  lesion  is  a  cerebral  contusion,  the  primary 
temperature  is  but  slightly  higher,  but  will  rise  progress- 
ively, and  in  a  certain  proportion  of  cases  will  be  marked 
by  recessions  which  do  not  attend  hemorrhages.  Cere- 
bral lacerations  are  characterized  by  a  still  higher  initial 
temperature,  and  when  severe  by  an  early  and  rapidly  pro- 
gressive increase  with  only  brief  and  unimportant  reces- 
sions, and  if  fatal  by  an  often  excessive  final  elevation. 
These  generalizations  result  from  an  analytical  study  of 
the  appended  series  of  cases.  If  then,  after  the  lapse  of 
hours,  consciousness  still  remains  in  abeyance,  a  stationar}'' 
temperature  but  one  or  two  degrees  above  the  normal 
standard  will  indicate  a  hemorrhage  of  some  profusion 
without  serious  cerebral  injury;  but  a  higher  elevation 
which  constantly  increases,  with  possible  recessions,  will 
point  to  a  visceral  lesion.  If  this  increasing  temperature 
does  not  exceed  moderate  limits  and  its  advance  is  slow, 
it  will  suggest  contusion  alone,  or  with  laceration  of  small 
extent ;  a  still  higher  early  temperature,  advancing  rapidly 
and  uninterruptedly  or  without  important  recessions,  is 
an  almost  pathognomonic  indication  of  laceration;  and  a 
resultant  cortical   or   a  coincident   other   form  of  hemor- 


DIAGNOSIS.  '  177 

rlaage  can  be  recognized  only  by  the  coexistence  of  some 
characteristic  symptom  of  a  different  nature.  In  occa- 
sional instances  of  cerebral  contusion  the  temperature  may 
as  rapidly  attain  a  high  degree  as  with  laceration,  and 
diagnosis  must  again  depend  upon  the  other  symptoms. 
The  cases  in  which  consciousness  after  a  brief  restoration 
is  again  lost,  permanently  or  for  a  lengthened  period,  have 
the  same  relations  to  temperature  as  those  in  which  un- 
consciousness has  been  uninterrupted.  It  will  be  recalled 
that  the  recurrence  of  unconsciousness  after  an  early  in- 
terval of  sensibility  is  indicative  of  an  increase  or  super- 
vention of  hemorrhage,  and  that  at  a  later  period  more  or 
less  conscious  intervals  in  a  generally  unconscious  condi- 
tion result  from  a  temporary  lessening  from  time  to  time 
of  the  hyperemia  or  oedema  of  a  diffuse  cerebral  contusion. 
The  question  of  hemorrhage  could  scarcely  be  mooted  in 
the  last  instance,  but  the  temperature  still  conforms  to 
established  rule. 

The  diagnostic  characters  of  the  pulse  and  respiration 
can  be  less  definitely  formulated.  In  uncomplicated 
hemorrhages  the  pulse  is  oftener  frequent  than  otherwise, 
and  in  cases  which  are  to  some  extent  complicated  it  is 
usually  normal;  but  the  exceptions  to  the  rule  are  so  nu- 
merous in  either  case  that  it  has  little  practical  importance. 
The  conditions  of  the  pulse  are  more  uniform  in  epidural 
hemorrhages  than  in  others,  and  slowness  and  fulness 
are  so  generally  noted  that  they  may  be  considered  fairly 
characteristic.  The  respiration  when  hemorrhage  is  pro- 
fuse and  practically  uncomplicated  is  only  exceptionally  of 
normal  character;  but  its  disturbances  are  without  recog- 
nizable relation  to  the  form  of  the  extravasation  or.  in 
Sfeneral.  to  its   situation.       Increased    or   diminished   fre- 


178  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

quency,  with  or  without  stertor,  occur  alike  whether  the 
effusion  is  epidural,  pial,  or  cortical,  or  whether  it  is  at  the 
base  or  vertex ;  but  infrequency  and  stertor,  like  slowness 
and  fulness  of  the  pulse,  are  more  nearly  characteristic  of 
epidural  than  of  other  forms  of  hemorrhage.  If  the  ex- 
travasated  blood  compresses  the  medulla,  the  fact  of 
hemorrhage,  its  position  and  its  source  in  the  pial  or  cor- 
tical vessels,  are  all  absolutely  demonstrated  by  extreme 
respiratory  infrequency;  this  certainty,  with  the  prob- 
ability of  an  epidural  form  of  hemorrhage,  when  the 
respiration  is  stertorous  and  moderately  infrequent,  sum- 
marize the  information  to  be  derived  from  a  study  of  this 
function  in  connection  with  intracranial  vascular  lesions. 

In  diffuse  cerebral  contusion  it  is  impossible  to  dis- 
cover any  variations  from  the  normal  pulse  and  respiration 
which  occur  with  sufficient  uniformity  to  afford  assistance 
in  diagnosis  in  individual  cases.  Neither  the  proportion 
of  cases  in  which  they  are  not  sensibly  affected,  nor  of 
those  in  which  they  are  increased  or  are  diminished  in  fre- 
quency, is  sufficiently  large  to  justify  positive  inference, 
though  both  incline  to  acceleration. 

In  case  of  the  cerebral  lesions  in  which  laceration  is  an 
essential  part,  a  more  uniform  condition  of  pulse  and 
respiration  can  be  predicated.  After  recovery  from  shock 
and  unless  meningeal  inflammation  supervenes,  the  fre- 
quency of  the  pulse  upon  early  examination  does  not  often 
exceed  90,  nor  the  respiration  26.  In  the  majority  of 
cases  the  pulse  is  full  and  slow  and  not  more  frequent  than 
from  60  to  70,  and  is  sometimes  but  40  in  the  minute.  If 
the  respiration  departs  from  its  normal  standard,  it  is  more 
likely  to  be  slightly  accelerated  than  retarded.  These 
conditions  are  maintained  till  recovery,  or,  if  the  case  is 


DIAGNOSIS.  179 

destined  to  a  fatal  termination,  until  the  patient  becomes 
asthenic.  The  contrast  so  often  presented  by  a  nearly- 
normal  and  unaccelerated  pulse  and  respiration,  with  a 
high  temperature  and  general  symptoms  of  perhaps  great 
severity,  is  not  only  striking,  but  is  of  great  value  in  diag- 
nosis. There  is  also  a  frequent  want  of  correspondence 
in  their  changes,  which  is  characteristic  when  they  suffer 
more  notable  disturbance,  the  pulse  becoming  slower  as 
the  respiration  is  accelerated.  The  irregular  rhythm  of 
respiration  which  sometimes  occurs  with  severe  cerebral 
lesion  is  not  observed  in  the  case  of  hemorrhages,  except 
as  a  symptom  of  coincident  contusion.  The  asymmetrical 
radial  pulsations  upon  opposite  sides  of  the  body,  which 
are  so  conclusive  of  the  existence  of  some  form  of  intra- 
cranial injury,  afford  no  clew  to  the  nature  of  the  lesion. 

Dyspnoea  and  resulting  cyanosis  are  not  referable  to 
compression  of  the  medulla,  but  of  the  intracranial  portion 
of  the  pneumogastric  nerve. 

An  importance  has  been  attributed  to  indications 
afforded  by  the  pupils  which  is  not  warranted  by  an  an- 
alysis of  cases.  They  are  so  often  normal,  and  when  ab- 
normal present  so  many  variations  in  dilatation  and  contrac- 
tion, that  their  observation  cannot  as  a  rule  materially  aid 
in  diagnosis.  The  paralysis  or  spastic  contraction  of 
muscular  fibres,  upon  which  their  changes  depend,  results 
from  cerebral  injury,  and,  as  they  occur  in  a  much  larger 
percentage  of  hemorrhages  than  of  the  essentially  visceral 
lesions,  it  would  appear  that  the  cortex,  which  is  coinci- 
dently  involved,  is  specially  connected  with  their  control. 
This  muscular  derangement  occurs,  however,  with  lesion 
of  every  part  of  the  brain,  whether  limited  or  diffuse,  and 
with  or  without  the  concurrence  of  hemorrhage ;  but  the 


l80  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

organic  conditions  which  determine  its  presence  or  ab- 
sence or  the  nature  of  its  manifestation  are  unknown. 
There  is  a  single  exception  to  be  made  to  this  statement 
of  the  pathology  and  of  the  diagnostic  value  of  pupillary 
change.  The  dilatation  of  the  corresponding  pupil  with  an 
epidural  hemorrhage  is  due  not  to  cerebral  injury,  but  to 
direct  pressure  of  the  extravasated  blood  upon  the  third 
cranial  nerve,  and,  having  a  definite  origin,  it  is  a  distinc- 
tive S5'mptom.  Still  it  is  neither  constant  nor  pathog- 
nomonic; there  are  many  epidural  hemorrhages,  even 
those  occasioned  by  rupture  of  the  middle  meningeal 
artery,  in  which  no  pressure  is  exerted  upon  the  nerve  and 
no  change  in  the  pupil  exists;  and  there  are  many  in- 
stances of  epidural  hemorrhage  with  dilatation  of  the 
opposite  pupil  from  some  coincident  cerebral  lesion. 

The  mental  disturbances  which  may  replace  or  imme- 
diately succeed  unconsciousness,  or  in  some  form  occur  at 
a  later  period,  are  all  indicative  of  visceral  lesion.  De- 
lirium is  always  the  result  of  circulatory  disturbance,  and 
as  an  early  symptom  must  be  distinguished  from  the  effect 
of  alcoholism,  and  later  from  the  same  condition  as  pro- 
duced by  sepsis  or  by  meningeal  inflammation.  If  promi- 
nent and  convincing  evidence  of  hemorrhage  or  of  lacera- 
tion exists,  it  is  to  be  attributed  not  to  those  lesions  but  to 
a  complicating  cortical  contusion.  Irritability,  restless- 
ness, or  other  sensory  disturbances  are  to  be  ascribed  to 
the  same  cause.  There  is  no  mental  disorder,  aside  from 
loss  of  consciousness,  which  results  from  hemorrhage. 
The  derangements  of  the  intellectual  faculties  which  are 
not  incidental  to  delirium,  as  delusions,  loss  of  memory, 
defective  judgment,  and  mental  decadence,  indicate  in  the 
great  majority  of  cases  laceration,  and  this  has  been  de- 


DIAGNOSIS.  l8l 

monstrated  by  conjoinea  clinical  and  necropsic  observation 
to  involve  the  left  frontal  lobe.  The  dependence  of  such 
symptoms  upon  general  contusion  is  possible  but  it  is 
exceptional. 

Loss  or  disorder  of  muscular  action  may  occur  with 
each  of  the  traumatic  intracranial  lesions,  but  either  is  an 
infrequent  result  of  uncomplicated  contusion.  Paralysis 
is  especially  characteristic  of  hemorrhages,  and  irregular 
muscular  action  of  laceration.  The  paralyses,  which  may 
be  either  complete  or  incomplete,  local  or  general,  are  due 
in  the  case  of  hemorrhage  to  compression,  and  in  lacera- 
tion to  disruption  of  recognized  motor  tracts  or  areas. 
General  or  local  convulsions,  muscular  twitchings,  and 
muscular  rigidity  are  occasioned  by  compression  and  irri- 
tation of  the  cortex  in  hemorrhage,  or  by  irritation  of  the 
contiguous  cerebral  substance  in  laceration.  The  cause  of 
these  several  motor  disturbances,  as  they  occur  in  indi- 
vidual cases,  may  be  to  some  extent  assumed  from  their 
known  relative  frequency  from  different  lesions.  This  is 
notably  true  of  convulsions  which  are  so  generally  the 
result  of  laceration.  The  indication  of  hemorrhage  or 
laceration  afforded  by  a  study  of  symptoms  collectively  is 
however,  more  directly  diagnostic,  and  the  relation  of  the 
pathic  motor  condition  to  special  associated  symptoms  has 
great  significance.  The  temperature  which  precedes  the 
convulsive  paroxysms  is  distinctly  higher  if  the  causative 
lesion  is  a  laceration  than  if  it  is  a  hemorrhage ;  the  im- 
mediate subsequent  temperature  has  no  corresponding 
value.  The  convulsions  which  result  from  hemorrhage, 
which  is  usually  pial,  are  likely  to  be  preceded  or  accom- 
panied by  paralysis,  which  is  improbable  if  they  are  due 
to  laceration.     The  precedence  or  coincidence  of  certain 


l82  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

mental  derangements  known  to  be  usually  connected  with 
frontal  lesion  will  greatly  add  to  the  probability  which  so 
generally  exists  that  any  convulsion  is  due  to  laceration  of 
the  temporo-frontal  region. 

The  loss  of  faecal  and  urinary  control  is  a  nearly  pathog- 
nomonic symptom  of  laceration.  It  is  fairly  constant  when 
life  is  prolonged  for  a  number  of  hours,  and  it  is  of  rare 
occurrence  when  cerebral  injury  is  confined  to  hemor- 
rhage or  contusion.  It  is  unaffected  by  the  region  of  brain 
involved,  and  is  independent  of  paralysis  or  the  loss  of 
consciousness.  The  retention  of  urine  which  sometimes 
occurs  in  cases  of  hemorrhage,  on  the  contrary,  is  not 
indicative  of  the  nature  of  the  lesion,  but  is  merely  a 
result  of  the  unconscious  state,  however  produced. 

The  several  pathic  conditions  which  have  been  enumer- 
ated possess  different  diagnostic  values.  Some  of  them, 
like  secondary  unconsciousness  or  loss  of  faecal  and  urinary 
control,  indicate  merely  the  nature  of  the  lesion;  others, 
like  special  forms  of  paralysis,  indicate  its  situation;  and 
others  still,  like  certain  mental  disorders  or  an  extreme 
infrequency  of  respiration,  indicate  both  its  nature  and  its 
exact  or  approximate  situation.  There  are  certain  other 
symptoms  which  might  be  possibly  encountered  and  in- 
terpreted in  the  light  of  physiological  investigation  as  ap- 
plied to  cerebral  localization.  It  might  be  supposed  that 
traumatic  lesion  of  the  occipital  visual  centre,  or  of  the 
temporo-sphenoidal  auditory  or  gustatory  centres,  if  such 
exist,  would  be  attended  by  default  or  aberration  of  the 
corresponding  special  senses.  If  these  effects  have  been 
recognized,  they  have  been  unrecorded — at  least  so  far  as 
taste  or  hearing  are  concerned. 

The  lesions  of  the  speech  centres  in  the  frontal  and 


DIAGNOSIS.  183 

temporal  lobes  are  not  infrequently  indicated  in  recovering 
cases  by  the  existence  of  motor  or  sensory  aphasia.  The 
very  general  coincidence  of  an  unconscious  or  delirious 
condition  renders  it  exceptional  as  a  recognizable  symptom 
in  those  which  are  fatal.  It  has  been  assumed  that  com- 
pression from  hemorrhage,  as  well  as  destructive  injury 
of  its  centres  of  control,  is  an  effective  cause  of  the  loss  or 
disturbance  of  the  faculty  of  speech.  This  assumption  is 
opposed  to  the  results  of  observation  and  not  less  to  gen- 
eral anatomical  and  pathological  considerations.  The 
compression,  if  exerted  by  a  small  amount  of  blood,  must 
be  direct  and  accurately  applied;  if  it  be  by  a  hemor- 
rhage large  enough  to  include  these  small  spaces  in  the 
wide  expanse  of  cerebral  surface  through  which  we  are 
brought  in  contact  with  the  world  without,  the  individual 
fault  is  lost  in  the  general  obscuration  of  all  the  faculties 
which  attends  the  grosser  injury.  A  pial  hemorrhage  from 
meningeal  contusion  in  this  region  is  likely  to  be  scant 
and  diffused;  a  cortical  hemorrhage,  if  small  and  confined 
to  either  area  in  which  the  control  of  speech  resides,  is 
derived  from  laceration  of  the  part  itself,  to  which  as  the 
primary  and  more  potent  lesion  the  result  must  be  at- 
tributed; an  epidural  hemorrhage  while  yet  in  moderate 
amount  acts  directly  and  inadequately  upon  the  temporal 
or  lower  frontal  region  through  the  dura,  which  serves  as 
an  efficient  shield.  In  the  case  of  wounds  of  the  middle 
meningeal  artery,  in  which  the  effusion  of  blood  may  in 
time  become  excessive,  the  loss  of  consciousness  which 
then  ensues  abrogates  speech  with  all  the  other  manifesta- 
tions of  intellectual  life.  In  the  large  number  of  hemor- 
rhages included  in  the  appended  series  of  cases,  none  of 
pial    or   cortical    origin    have    suggested    an    interference 


184  INJURIES    OF   THE    BRAIN   AND    MEMBRANES, 

with  the  integrity  of  speech,  and  in  none  in  which  con- 
sciousness has  been  retained  or  restored  has  blood  de- 
scended from  the  vertex  in  sufficient  quantity  to  produce 
such  a  result  by  compression  of  the  frontal  or  temporal 
lobe.  They  include  instances  of  large  epidural  hemor- 
rhage in  which  consciousness  was  gradually  lost  before 
death  or  relief  by  operation,  but  none  in  which  aphasic 
symptoms  were  recognized  at  any  time  during  their  prog- 
ress. There  is  a  case  reported  in  which  motor  aphasia  is 
attributed  to  hemorrage.  The  effusion  was  small;  the 
patient  was  trephined,  and  some  power  of  speech  regained 
as  well  as  some  improvement  made  in  an  impaired  mental 
condition.  It  has  been  demonstrated  from  extensive  ob- 
servations that  intellectual  and  emotional  impairment  is 
not  occasioned  by  traumatic  hemorrhage.  There  were 
evidences  of  both  in  this  case  which  the  amount  of  blood 
discovered  and  removed  was  certainly  insufficient  to  ex- 
plain. It  is  necessary  to  assume  laceration  in  order  to  ac- 
count for  their  existence,  and  it  seems  more  probable  that 
the  same  lesion  was  the  cause  of  the  aphasia,  which  might 
readily  have  escaped  notice  in  the  comparatively  small 
opening  of  operation,  especially  if  it  were  entirely  subcor- 
tical within  the  visual  area.  The  patient  after  the  lapse 
of  some  years  was  still  aphasic.  It  may  be  added  that  it 
by  no  means  followed  that  hemorrhage  was  the  cause  of 
symptoms  because  immediate  improvement  succeeded 
operation.  The  removal  of  a  small  portion  of  bone  by  the 
trephine  not  infrequently  relieves  morbid  cerebral  condi- 
tions, though  the  lesion  remains  undiscovered.  Examples 
of  successful  results  from  operative  failure  in  cranial  sur- 
gery are  as  varied  as  the  conditions  which  demand  inter- 
ference ;  one  such  may  be  cited  from  the  appended  series 


DIAGNOSIS.  185 

of  cases,  in  which  traumatic  convulsions  of  several  days' 
continuance  were  immediately  and  permanently  controlled 
by  trephining  both  in  the  region  of  direct  injury  and  at 
the  supposed  point  of  contrecoup,  though  nothing  abnormal 
was  discovered  and  nothing  more  was  done. 

It  is  evident  from  this  rehearsal  and  alignment  of  in- 
dications that  the  primary  factors  in  the  diagnosis  of  trau- 
matic intracranial  lesions  are  the  absolute  and  relative 
characters  of  the  pulse,  temperature,  and  respiration,  and 
the  varied  phases  of  unconsciousness.  The  other  pathic 
conditions  presented  are  accidental  in  the  sense  of  incon- 
stancy, but  the  existence  of  one  or  more  of  them  may  be 
probably  assumed  in  the  majority  of  cases.  The  consider- 
ation which  has  been  given  to  the  history  and  progression 
of  symptoms  demonstrates  their"  constantly  varying  indi- 
vidual significance  in  either  class,  and  the  necessity  for 
their  accurate  observation  and  careful  comparison  in  each 
particular  instance.  It  may  happen  in  the  end  that  it  is 
still  impossible  to  arrive  at  certainty,  and  a  conclusion 
must  be  based  upon  a  just  estimate  of  probabilities,  in 
forming  which  the  experience  and  sagacity  of  the  surgeon 
may  become  conspicuous. 

SECONDARY   INFLAMMATIONS. 

I.    Arachnitis. 

The  diagnosis  of  acute  arachnitis  is  probably  impossible 
at  the  outset,  if  its  invasion  immediately  succeeds  the  pri- 
mary injury.  Its  indications  then  are  not  only  illy  de- 
fined, but  are  hidden  by  those  of  the  original  contusion 
and  possibly  by  those  of  coincident  lesions.  If  its  invasion 
is  also  insidious,  diagnosis  may  be  no  more  than  conject- 


1 86  IN-JURIES    OF   THE    BRAIN    AND    MEMBRANES. 

ural  even  at  a  later  period.  If  again  the  inflammatory 
process  is  acute  as  well  as  immediate,  its  onset  will  be  ap- 
parent by  the  occurrence  of  a  sthenic  constitutional  reac- 
tion, of  which  the  symptoms  will  be  consistent  with  each 
other.  The  chill  will  probably  be  absent,  and  the  tem- 
perature be  no  higher  than  is  common  with  simple  lacera- 
tions ;  but  the  respiration  will  be  hurried  and  frequent,  and 
the  pulse  full  and  strong  as  well  as  rapid,  in  contrast  with 
the  nearly  normal  or  retarded  pulse  and  respiration  which 
characterize  cerebral  lesions  with  a  high  temperature. 
The  delirium  too  will  be  more  active,  the  heat  of  surface 
greater,  and  vomiting  more  likely  to  occur.  In  the  more 
frequent  instances  in  which  an  arachnitis  of  greater  or  less 
intensity  is  developd  some  days  after  the  reception  of 
meningeal  injury,  its  invasion  is  marked  by  an  abrupt 
change  in  the  condition  of  the  patient  which  is  character- 
istic. The  course  of  symptoms  referable  to  the  primary 
lesion  is  interrupted  by  a  somewhat  sudden  rise  in  temper- 
ature, and  by  the  manifestation  of  mental  and  sensory  dis- 
turbances. The  temperature,  whatever  may  be  its  course 
in  idiopathic  cases,  is  subject  to  irregular  and  sometimes 
very  marked  daily  recessions.  The  irritability,  restless- 
ness, delirium,  or  somnolence,  which  are  persistent  as  well 
as  invasive  symptoms,  are  often  in  distinct  contrast  to  the 
conditions  which  had  previously  existed.  The  sudden  rise 
and  often  notable  subsequent  fluctuations  of  temperature, 
and  the  varied  manifestations  of  cortical  irritation,  are  in 
general  the  only  direct  means  of  recognizing  the  menin- 
geal inflammatory  process,  whether  it  results  from  infec- 
tion or  from  a  continuance  of  the  original  structural 
changes.  The  occurrence  of  post-cervical  or  general  mus- 
cular rigidity  is  confined   to  cases  which  secondarily  in- 


DIAGNOSIS.  187 

volve  the  spinal  membranes,  as  disordered  function  from 
implication  of  the  cranial  nerves  exists  only  when  the  dis- 
ease extends  to  the  basilar  region.  In  the  cases  in  which 
the  inflammation  is  wholly  or  mainly  limited  to  the  vertex, 
and  which  perhaps  constitute  the  majority,  such  localizing 
symptoms  are  almost  impossible.  Paralyses  involving  the 
extremities  are  not  to  be  expected,  since  the  disease  usu- 
ally terminates  in  fatal  asthenia  before  the  effusion  is 
sufficiently  large  to  interfere  by  pressure  with  either  con- 
sciousness or  muscular  action.  In  the  larger  number  of 
cases,  whatever  the  period  of  their  development  and 
whatever  the  grade  of  inflammation,  the  pulse  and  respira- 
tion are  not  affected  to  a  degree  which  challenges  atten- 
tion. There  are  no  symptoms  which,  in  themselves  and 
apart  from  attendant  circumstances,  are  either  pathogno- 
monic or  even  characteristic. 

The  character  of  the  effusion  cannot  be  inferred  with 
any  certainty  from  a  study  of  symptoms.  The  occurrence 
of  chill,  with  a  pulse,  temperature,  and  respiration  denoting 
a  sthenic  constitutional  reaction,  and  with  active  delirium, 
may  properly  be  taken  to  indicate  the  formation  of  pus ; 
but  the  chill  may  be  absent  when  suppuration  is  profuse, 
or  present  when  the  effusion  is  wholly  serous  or  sero-fibri- 
nous,  and  it  is  probably  rather  the  measure  of  the  suscepti- 
bility of  the  patient's  nervous  system  to  irritation  than  of 
the  height  of  the  inflammatory  process.  In  like  manner 
the  invasion  and  progress  of  the  inflammation  may  be  ex- 
tremely insidious  though  the  event  is  suppurative,  or  the 
constitutional  reaction  may  be  severe  when  the  exudation 
is  simply  serous.  If  the  inflammation  is  known  to  be  in- 
fective, the  purulent  character  of  the  effusion  can  hardly 
be  in  doubt,  though  the  symptoms  may  be  ambiguous.     A 


1 88  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

traumatic  arachnitis  in  young  subjects  sometimes  assumes 
a  tuberculous  character;  this  may  be  suspected  from  the 
successive  implication  of  cranial  and  spinal  nerves,  which 
indicates  its  basal  situation,  and  from  the  sluggish  prog- 
ress and  great  prolongation  of  the  disease. 

2.  Abscess. 

Parenchymatous,  like  meningeal  inflammation,  when 
traumatic,  is  probably  always  a  continuance  of  structural 
changes  which  begin  in  an  original  contusion,  and,  with  or 
without  the  intervention  of  an  infective  organism,  ter- 
minate in  the  leucocytal  migration.  It  differs  from  menin- 
geal inflammation  in  the  fact  of  invariable  defeat  of  the 
leucocytes  and  formation  of  pus.  If  this  process  is  vig- 
orous and  rapid,  its  diagnosis  may  come  in  question  before 
the  disappearance  of  the  symptoms  of  the  primary  lesion, 
and  while  the  liability  to  the  development  of  an  arachnoid 
inflammation  still  exists.  It  oftener  happens  that  the  in- 
dications of  abscess  begin  to  be  evident  only  after  the  lapse 
of  weeks  or  months,  and  perhaps  not  till  the  occurrence  of 
an  original  injury  has  been  forgotten.  If  in  the  interval 
the  patient  has  been  unobservant  of  himself  and  has  not 
deviated  from  his  usual  habits  of  life,  the  symptoms  which 
finally  compel  attention  may  seem  very  obscure. 

The  exceptional  instance  of  what  may  be  termed  a 
primary  cerebral  abscess  must  be  diagnosticated  from  its 
still  existent  source,  cerebral  contusion  or  laceration,  and 
from  arachnoid  inflammation.  It  is  doubtful  if  the  earliest 
constitutional  reaction  from  the  local  inflammation  can 
be  distinguished  from  that  which  attends  an  arachnitis. 
Such  differences  as  exist  are  not  greater  than  those  which 
may  occur  in  individual  instances  of  either  disease.      It  is 


DIAGNOSIS.  189 

only  as  they  progress  further  that  their  symptoms  diverge ; 
greater  cortical  irritation,  fluctuating  and  increasing  tem- 
perature, and  possibly  an  implication  of  the  cranial  nerves, 
in  arachnitis ;  decreasing  temperature,  more  rapid  and  ex- 
tensive nutritive  changes,  and  more  notable  disturbances 
of  functional  control  from  pressure,  in  abscess.  The  dif- 
ferentiation from  the  antecedent  and  concurrent  visceral 
lesion,  if  practicable,  is  made,  as  in  arachnitis,  by  the  pre- 
dominance of  the  constitutional  evidences  of  an  inflam- 
matory process  over  those  of  a  simply  destructive  local 
change.  After  the  initial  symptoms  have  given  place  to 
those  of  an  existent  body  of  pus,  the  conditions  do  not 
differ  from  those  of  the  more  usual  chronic  abscess,  ex- 
cept that  there  is  available  a  continuous  history  and  con- 
sequently the  means  for  a  more  facile  interpretation  of  the 
phenomena  presented.  The  abscess  of  more  lengthened 
and  insidious  development  may  manifest  itself  after  weeks 
or  months  of  apparent  quiescence,  either  abruptly  or  by 
the  gradually  increasing  gravity  of  symptoms  which  have 
flnally  come  to  challenge  attention.  In  the  first  case, 
diagnosis  is  to  be  made  from  sudden  vascular  lesion,  and 
in  the  second,  from  the  results  of  an  older  vascular  lesion 
and  from  tumor.  It  may  also  happen  that  one  condition 
may  be  engrafted  upon  the  other ;  persistent  symptoms  of 
more  or  less  urgency  then  terminate  in  some  distinct  crisis, 
but  without  raising  new  issues  in  diagnosis.  In  a  large 
proportion  of  late  abscesses  of  traumatic  origin  it  is  possi- 
ble to  discover  or  to  surmise  the  antecedent  cranial  injury; 
this  in  otherwise  obscure  cases  may  be  an  essential  factor 
in  determining  the  nature  of  the  lesion.  The  fact  that  an 
injury  of  the  head  has  been  sustained,  even  without  a  his- 
tory of  cerebral  implication,  is  entitled  to  great  weight  in 


1 90  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

the  final  summary  of  indications,  as  in  other  cases  of 
abscess  is  the  presence  of  an  otitis  media  or  other  evident 
source  of  possible  infection.  If  the  occurrence  of  the 
primary  cerebral  contusion  or  laceration  is  undoubted, 
there  will  be  little  difficulty  in  interpreting  the  symptoms 
of  its  inflammatory  sequel.  It  would  be  improbable,  at 
least,  that  cerebral  softening  from  thrombosis  or  embo- 
lism, or  that  a  morbid  growth  should  occur  at  this  time. 
There  are  certain  broad  distinctions,  however,  indepen- 
dent of  a  history  of  traumatism  or  of  a  discoverable  source 
of  purulent  infection,  in  the  symptomatology  of  cerebral 
softening,  abscess,  and  tumor,  which  will  ordinarily  serve 
for  their  differentiation. 

Structural  change  in  the  brain  tissue  from  vascular  ob- 
struction is  so  much  more  frequent  than  the  formation  of 
abscess  or  tumor  that  it  is  naturally  first  suspected  in  cases 
in  which  paralyses  occur  with  progressive  mental  deca- 
dence. These  conditions,  with  some  impairment  of  the 
general  health,  are  common  to  all  organic  diseases  of  the 
brain,  and  together  with  anaesthesia,  aphasia,  and  hemi- 
anopsia are  also  localizing  symptoms,  but  not  diagnostic 
of  the  nature  of  the  lesion ;  they  simply  serve  to  narrow 
the  field  of  inquiry.  If  the  radial  arteries  are  rigid,  if 
the  cardiac  valves  are  thickened,  or  if  the  patient  is  ad- 
vanced in  life,  or  if,  younger,  he  has  been  contaminated  b)'- 
syphilis,  the  probability  of  a  simple  cerebral  softening  is 
increased.  The  absence  of  symptoms  which  are  directly 
characteristic  of  abscess  or  tumor  renders  this  probability 
as  near  an  approach  to  certainty  as  can  be  attained. 

There  are  certain  additional  symptoms  \Nhich  are  in- 
dicative of  both  abscess  and  tumor,  but  not  of  softening; 
these  are  the  result  of  increased  intracranial  pressure,  and 


DIAGNOSIS.  191 

are:  headache,  vertigo,  slow  pulse  and  respiration,  con- 
vulsions, optic  neuritis,  dilatation  of  the  pupil,  and  a  sub- 
normal temperature.  There  is  a  still  further  indication 
noted  by  Dr.  J.  F.  Eskridge.  He  has  been  led  to  con- 
clude from  a  number  of  observations  that  in  irritative 
lesions  a  sustained  temperature  from  ^°  to  1°  higher  on 
the  paralyzed  side,  several  weeks  after  paralysis  has  be- 
come manifest,  is  characteristic.  A  bilateral  variation  of 
axillary  temperatures  may  be  occasionally  observed  in  cases 
of  cerebral  softening,  but  it  is  not  sustained  and  not  uni- 
form. Extreme  variations  have  been  noted  also  in  some 
of  the  appended  histories  of  intracranial  injuries,  but  they 
were  ephemeral,  and  inconstant  in  their  relation  to  the  site 
of  the  lesion.  This  point  in  diagnosis  seems  worthy  of 
more  extended  observation. 

The  final  analytic  process  by  which  abscess  is  to  be 
differentiated  from  tumor  requires  not  only  the  recogni- 
tion of  its  positively  distinctive  symptoms,  if  such  exist, 
but  an  estimation  of  the  comparative  value  of  those  com- 
mon to  both  diseases  as  they  occur  in  either  one,  and  a 
continuous  regard  for  suggestive  facts  in  the  history  of  the 
patient.  It  is  questionable  if  any  symptom  is  pathogno- 
monic, unless  it  be  the  occasional  escape  of  pus  through  a 
cerebral  sinus,  though  the  continued  rigidity  of  more  or 
less  paralyzed  muscles  for  days  at  a  time  has  been  regarded 
by  Eskridge  as  positive  evidence  in  cases  of  abscess  in 
which  tumor  is  the  alternative.  In  general,  the  emacia- 
tion and  prostration  of  the  patient  are  more  marked  and 
more  rapidly  progressive  than  occur  in  connection  with 
the  growth  of  tumors,  and  the  temperature  is  more  fre- 
quently, persistently,  and  distinctly  subnormal.  The 
changes  in  the  optic  discs,  on  the  contrary,  are  less  fre- 


192  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

quent  and  less  pronounced  in  the  formation  of  abscess. 
These  differences,  while  not  absolutely  determinate  of  the 
nature  of  the  lesion,  are  sufficiently  characteristic  to  be- 
come important  factors  in  diagnosis.  It  is  still  to  be  re- 
membered that  a  subnormal  temperature,  choked  discs,  or 
marked  failure  of  the  general  nutrition,  may  exceptionally 
attend  even  vascular  occlusion.  Variations  in  the  size  or 
stability  of  the  pupils,  and  headaches  of  different  degrees 
of  severity  and  persistency,  are  equally  observed  in  tumor 
and  in  abscess,  and  under  similar  conditions.  The  ab- 
sence of  such  coincidents  as  syphilitic  or  tuberculous  infec- 
tion, or  of  the  cancerous  cachexia  and  their  local  manifesta- 
tions in  other  parts  of  the  body,  and  following  the  exclusion 
of  predispositions  to  embolism  or  thrombosis,  will  of  course 
add  to  the  probability  which  exists  that  symptoms  common 
to  both  are  due  to  abscess  in  a  given  case  rather  than  to 
tumor. 

In  every  case  of  manifest  disease  of  the  brain  substance, 
the  distinctive  character  of  the  lesion  is  to  be  sought  in  the 
study  of  its  etiology ;  this  quest  if  successful  will  furnish 
the  key  to  the  correct  interpretation  of  symptoms  other- 
wise obscure. 


Chapter  V. 

PROGNOSIS. 

A.— DIRECT  LESIONS. 

The  chances  of  recovery  from  intracranial  injury  may 
be  estimated  in  part  from  the  results  which  have  been  ob- 
served in  large  numbers  of  cases.  Conclusions  formed 
upon  a  purely  statistical  basis  are  generally  to  be  dis- 
trusted, but  the  cases  which  have  served  for  the  present 
study  of  these  lesions  have  been  so  many,  and  the  methods 
employed  for  their  diagnosis  have  been  so  uniform  and  so 
fully  detailed,  that  their  tabulation  will  have  some  special 
value.  The  method  of  treatment  adopted  may  determine 
the  issue  in  individual  instances,  but  will  exert  no  sen- 
sible influence  upon  general  results  when  the  aggregate 
number  of  observations  is  large,  and  may  be  assumed  to 
be  immaterial. 

The  five  hundred  cases,  upon  the  observation  of  which 
this  consideration  of  intracranial  injuries  has  been  based, 
may  be  classified  primarily  in  reference  to  their  general 
mortality. 

I.   Fractures  Involving  the  Base  of  the  Cranium. 
Recovered,         .         .         .         .         .no 
Died, 176—286 

Number  of  necropsies,       .         .         .   146 
13 


194  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

11.   Fractures  ConJi)icd  to  the  Vertex  of  the  Cranium. 
Recovered,  .         .         .         .         .75 

Died,  ......  41 — 116 

Number  of  necropsies,  .  .  .34 

III.   Encephalic  Injuries  not  Accompanied  by  Fracture 
of  the  Cranium. 
Recovered,  .  .  .  .  -41 

Died 57 — 98 

Number  of  necropsies,  .         .  -45 

Summary. 

Total  number  of  recoveries,  .  .   226 

Total  number  of  deaths,       .  .  .   274 

Total  number  of  necropsies,  .  .225 

This  classification,  which  is  not  directly  one  of  intra- 
cranial injuries,  is  essentially  such,  since  fractures  of  the 
cranium  necessarily  involve  at  least  a  cerebral  contusion, 
and  are  usually  more  seriously  complicated. 

The  percentage  of  recoveries  is  much  greater  than 
might  have  been  expected  in  view  of  the  fact  that  en- 
cephalic lesions,  and  especially  those  which  complicate 
fractures  of  the  cranial  base,  have  been  long  regarded  as  of 
exceptionally  fatal  character.  The  proportion  of  recover- 
ies from  intracranial  injury  is  indeed  even  larger  than  is 
indicated  by  the  numerical  percentage  in  the  present  series 
of  cases.  These  were  of  more  than  average  severity,  and 
the  least  urgent  were  sufficiently  important  to  demand 
hospital  relief.  They  also  include  a  considerable  number 
of  pistol-shot  wounds,  in  which  the  fatality  markedly  ex- 
ceeds that  of  the  general  class  of  intracranial  traumatisms. 
It  is  to  be  further  noted  that  in  many  instances  death  was 
almost  immediate,  and  that  these  largely  outnumber  those 


PROGNOSIS.  195 

whicli  proved  to  be  relatively  unimportant.  If,  therefore, 
regard  were  had  only  to  those  cases  in  which  the  evidence 
of  lesion  is  distinct  but  in  which  time  suffices  for  prognosis 
and  treatment,  and  pistol-shot  wounds  were  excluded,  the 
average  of  recovery  would  be,  not  somewhat  less,  but 
considerably  more  than  fifty  per  cent,  of  their  whole 
number. 

The  very  different  percentages  of  recovery,  as  the 
cranial  base  or  vertex  may  be  fractured,  only  indicate  the 
greater  liability  of  the  one  to  dangerous  intracranial  com- 
plication as  compared  with  the  other.  The  proportion  of 
deaths  to  recoveries,  when  intracranial  injury  is  unaccom- 
panied by  cranial  wound,  is  only  of  statistical  interest. 
The  value  of  these  deductions  when  made  is  entirely  apart 
from  the  question  of  prognosis  in  individual  cases.  In 
general  it  may  be  said  that  the  danger  from  encephalic 
lesion,  when  force  is  solely  exerted  through  the  bone  at 
and  about  its  point  of  impact  upon  the  cranial  vertex,  is 
scarcely  more  than  one-half  that  which  attends  when  it  is 
also  transmitted  through  the  cranial  base ;  and  that  when 
force  is  entirely  expended  upon  the  intracranial  contents, 
as  it  was  in  nearly  twenty  per  cent  of  the  series  of  five 
hundred  cases,  danger  is  somewhat  less  than  when  the 
cranial  base  is  implicated.  This  difference  is  probably 
due  to  the  exclusion  of  epidural  hemorrhages,  which  occur 
in  serious  amount  only  as  a  complication  of  fracture. 

It  is  difficult  to  estimate  the  comparative  danger  of  the 
several  lesions,  from  the  fact  that  they  are  so  generally 
multiple,  and  all  together  conspire  to  bring  about  a  fatal 
result.  It  is  also  true  that  the  severity  rather  than  the 
form  of  lesion  is  to  be  made  the  basis  of  prognosis.  It 
may  be  impossible  therefore  to  infer  their  relative  danger 


196  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 


from  the  mere  frequency  with  which  different  lesions  have 
been  found  to  exist  in  fatal  cases ;  but  an  opinion  may  be 
approximated  by  the  tabulation  of  those  which  have  oc- 
curred, separately  or  in  conjunction,  and  in  degree  ap- 
parently sufficient  to  occasion  distinct  symptoms,  omitting 
reference  to  those  which  are  obviously  trivial  and  probably 
void  of  effect.  This  course  has  been  pursued  in  an  ex- 
amination of  the  two  hundred  and  twenty-five  appended 
cases  which  were  subjected  to  necropsy.  The  resulting 
tables  which  follow  are  as  nearly  accurate  as  the  com- 
plexity of  the  subject  will  allow.  General  contusion  is 
unmentioned  in  connection  with  lacerations,  though  it  al- 
ways exists  in  greater  or  less  degree,  and  is  often  the  es- 
sential cause  of  death. 

I.  Fractures  of  the  Crania!  Base. 

Laceration  and  more  or  less  consequent 

cortical  hemorrhage. 
Laceration  and  meningeal  contusion, 
Laceration  and  epidural  hemorrhage, 
Meningeal  contusion. 
General  cerebral  contusion. 
Meningeal  and  general  cerebral  con 

tusion,      ..... 
Epidural  hemorrhage. 
Epidural     hemorrhage     and     general 

cerebral  contusion, 
Abscess,       ..... 

n.   Fractures  of  the  Cranial  Vertex. 

Laceration  and  more  or  less  consequent 

cortical  hemorrhage. 
Laceration  and  epidural  hemorrhage,  . 


74 
13 
10 
1 1 
9 

5 

12 

10 

2- 


28 
I 


•  146 


PROGNOSIS. 


197 


10 

10 

3 

5 

I 


Meningeal  contusion,            ...  2 
Meningeal  and  general  cerebral   con- 
tusion,     ......  I 

Epidural  hemorrhage,  .         .         .  2 —  34 

III.   Encephalic  Injuries- without  Cranial  Fractures. 
Laceration  and  more  or  less  consequent 
cortical  hemorrhage, 
Laceration  and  meningeal  contusion,  . 
Meningeal  contusion,  .... 

General  cerebral  contusion, 
Meningeal  and  general  cerebral  con- 
tusion,     ...... 

Epidural  hemorrhage, 
Epidural  hemorrhage  and  general  con- 
tusion,     .....  .     2 —  45 

Summary. 
Laceration  and  cortical  hemorrhage, 
Laceration  and  meningeal  contusion, 
Laceration  and  epidural  hemorrhage, 
Meningeal  contusion,  . 
'  General  contusion, 
Meningeal  and  general  contusion, 
Epidural  hemorrhage. 
Epidural  hemorrhage  and  general  con 
tusion,      ......      12 

Abscess, 2—225 

Arachnitis  resulted  from  meningeal  contusion  in  fifteen 
cases ;  eight  of  these  were  in  conjunction  with  fractured 
base,  two  with  fractured  vertex,  and  five  were  independent 
of  cranial  injury.  In  each  case  of  abscess  it  chanced  that 
the  cranial  base  was  fractured. 


1 12 

23 
1 1 
16 

14 
20 

15 


igS  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

The  relative  importance  of  the  cerebral  wound,  its  re- 
sultant hemorrhage,  and  its  attendant  general  contusion, 
are  too  often  impossible  to  estimate  with  precision  to  permit 
a  further  subdivision  of  the  cases  in  which  laceration  is  a 
prominent  lesion.  It  sometimes  happens  that  a  cerebral 
wound  comparatively  trivial  in  extent  occasions  an  enor- 
mous hemorrhage,  or  that  with  great  destruction  of  cere- 
bral tissue  but  little  blood  is  lost,  or  that  the  concomitant 
general  contusion  is  obviously  serious  or  is  insignificant;  it 
then  becomes  easy  to  apportion  or  to  limit  the  responsibil- 
ity for  the  fatal  result.  In  the  majority  of  cases,  if  the 
primary  shock  of  general  contusion  is  surmounted,  it  is 
probable  that  when  laceration  is  of  much  extent  it  is  to  be 
accounted  the  essential  cause  of  death ;  cortical  hemorrhage 
is  but  an  incident  of  the  cerebral  wound.  If  another  form 
of  hemorrhage,  or  an  inflammatory  sequel  coexist,  the  lac- 
eration may  perhaps  be  held  a  less  influential  factor  in 
compassing  the  final  issue. 

An  analysis  of  recovering  cases,  with  a  view  to  the  de- 
termination in  each,  of  the  existing  lesions,  as  the  comple- 
ment of  the  similar  examination  of  those  which  are  fatal, 
affords  results  which  are  less  definite  because  incapable  of 
verification.  Errors  in  diagnosis  are  to  some  extent  in- 
evitable ;  and  yet  in  a  very  large  proportion  of  cases  the 
nature  of  the  dominant  lesion  can  be  established  with  a 
fair  approach  to  certainty.  The  diagnosis  in  each  of  the 
two  hundred  and  twenty-six  cases  of  recovery  in  the  present 
series  of  intracranial  injuries  was  made  after  careful  study, 
and,  conceding  its  correctness,  justifies  the  appended  sum- 
mary of  the  lesions  which  were  paramount.  In  twenty  of 
these,  a  fracture  of  the  base  or  vertex  was  so  nearly  un- 
complicated that  the  trivial  cerebral  contusion,  which  may 


PROGNOSIS. 


199 


be  assumed  to  have  existed,  has  been  disregarded  and  the 
case  omitted  from  the  tabulation. 


I.  Fracture  of  the  Cranial  Base. 
General  contusion, 
Laceration,  .... 

General  contusion  and  hemorrhage, 
Epidural  hemorrhage, 
II.  Fracture  of  Cranial  Vertex. 
General  contusion, 
Laceration,  .... 

Meningeal  contusion,  . 
Epidural  hemorrhage. 
Superficial  abscess, 
Central  abscess,  . 

III.   Encephalic  Injuries  without  Fracture. 

General  contusion,       .... 
Laceration,  ..... 

Epidural  hemorrhage, 
Epidural     hemorrhage     and     general 
contusion,  ..... 

Summary. 
General  contusion,       .... 

Laceration,  ..... 

Epidural  hemorrhage, 
Meningeal  contusion,  ,         .         . 

General  contusion  and  epidural  hem- 
orrhage,  ...... 

Superficial  abscess,       .         .         .         • 

Central  abscess,  .         . 

The  preponderance  assigned  to  general  contusion  as 

the  direct  cause  of  death  is  perhaps  not  entirely  warranted. 


57 
24 

9 

3—  93 

57 

12 

2 

5 
I 

I-  78 

14 

17 

3 

I—  35 


128 

53 

1 1 

2 

10 
I 
I- 


-206 


200  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

In  many  instances  in  which  doubt  might  fairly  exist  whether 
the  brain  lesion  included  laceration,  it  was  rated  as  simple 
contusion  in  the  absence  of  positive  evidence  of  the  fur- 
ther injury.  It  is  not  improbable  that  in  this  way  lacera- 
tion of  moderate  extent  has  been  sometimes  unnoted  and 
its  frequency  in  recovering  cases  somewhat  underrated. 
In  other  instances  contusion  has  been  inferred  from  the 
simple  character  or  brief  duration  of  the  symptoms;  this  is 
proper  ground  for  diagnosis,  but  it  occasionally  happens 
that  lacerations  are  discovered  after  death  which  have 
been  unsuspected  from  a  history  of  w'hich  all  the  details 
were  well  known.  If  full  allowance  be  made  for  such 
errors  in  classification,  there  will  still  remain  sufficient 
clinical  evidence  that  general  contusion  is  the  essential, 
if  not  the  sole  lesion  in  as  large  a  majority  of  recovering 
cases  as  is  laceration  in  those  which  are  fatal.  Menin- 
geal contusion  is  but  twice  mentioned  as  a  recognized 
lesion  when  recovery  ensued,  and  in  each  instance  was 
manifest  by  the  direct  exposure  of  the  oedematous  sub- 
arachnoid tissue.  It  can  hardly  be  doubted  from  its  fre- 
quent occurrence  in  fatal  injuries  that  this  change  must 
constitute  a  part  of  many  of  the  general  contusions  which 
have  a  favorable  issue.  It  is  also  possible  that  symptoms 
ascribed  to  a  general  contusion  with  epidural  hemorrhage 
may  be  often  due  to  a  pial  hemorrhage  from  meningeal 
implication,  but  in  the  absence  of  direct  knowledge  the 
more  conservative  course  has  been  taken  of  assuming  the 
general  condition.  The  diagnosis  in  many  instances  was 
more  precise  than  would  appear  from  the  tabulations  which 
have  been  made,  but  the  less  specific  statements  are  safer 
and  sufficient  for  the  present  purpose. 

The  comparison  of  summaries  in  the  fatal  and  recovering 


PROGNOSIS.  201 

cases  seems  to  indicate  that  laceration,  with  its  incidental 
hemorrhage,  is  at  once  the  most  frequent  and  the  most 
dangerous  of  all  lesions  in  cases  of  severity,  and  that 
general  contusion  is  by  far  the  most  frequent  in  those 
cases  which  are  of  milder  type.  It  affords  no  means  of 
estimating  the  absolute  danger  of  epidural  hemorrhage  or 
of  meningeal  contusion,  which  must  depend  in  either  one 
upon  the  amount  and  situation  of  the  extravasation,  and  in 
case  of  meningeal  contusion  upon  the  possible  occurrence 
of  a  subsequent  inflammatory  process. 

The  probability  of  the  existence  of  particular  lesions  in 
cases  of  indeterminate  character,  based  upon  their  known 
frequency  and  the  estimation  of  their  relative  danger  from 
previous  observations,  will  have  a  certain  prognostic  value. 
The  result  to  be  expected  in  individual  instances  will  di- 
rectly depend  upon  the  symptoms  presented,  as  indicating 
the  extent  rather  than  the  nature  of  the  injury  which  has 
been  sustained.  The  uncertainty  which  attends  the  issue 
of  an  intracranial  traumatism  is  great,  not  only  at  the  be- 
ginning, but  at  a  later  period  when  recovery  is  apparently 
assured.  The  immediate  danger  is  to  be  measured  by  the 
profundity  of  shock,  the  depression  of  temperature,  and 
the  enfeeblement  of  pulse,  and  in  some  instances  by  the  ex- 
tent of  visible  injury ;  but  reaction  is  still  possible  under 
conditions  which  seem  to  be  hopeless.  The  question  of 
prognosis  which  more  seriously  involves  the  judgment  of 
the  surgeon  arises  with  the  passing  of  this  initiatory  stage. 
It  will  suffice  to  indicate  some  of  the  more  characteristic 
symptomatic  phenomena  which  presage  the  impending 
course  and  termination  of  these  cases  of  encephalic  injury. 

Neither  depth  nor  prolongation  of  primary  unconscious- 
ness is  in  itself  a  measure  of  danger.     It  is  not  unusual  for 


202  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

complete  loss  of  consciousness  to  continue  for  some  days 
without  concomitant  or  subsequent  symptoms  of  special 
severity.  If,  however,  during  this  time  pulse,  tempera- 
ture, or  other  sj^mptoms  maintain  or  assume  an  unfavora- 
ble character,  the  mental  default  with  which  they  are  asso- 
ciated may  then  be  regarded  as  further  increasing  the 
gravity  of  prognosis.  The  loss  of  consciousness  which 
occurs  at  a  later  stage  of  the  case  is  always  of  grave  im- 
port ;  it  is  then  a  manifestation  of  an  increase  of  cerebral 
oedema,  a  meningeal  inflammatory  effusion,  septic  infec- 
tion, or  of  the  asthenic  condition  of  the  patient. 

The  temperature  from  first  to  last  in  prognosis,  as  in 
diagnosis,  transcends  in  importance  all  the  other  sympto- 
matic indications.  It  gauges  by  its  depression  and  by  its 
persistence  the  danger  from  primary  shock,  and,  a  little 
later,  the  amount  of  a  hemorrhage  which  may  be  other- 
wise known  to  exist.  At  a  somewhat  later  period  its  rapid 
and  progressive  rise  will  denote  the  magnitude  or  severity 
of  a  meningeal  or  cerebral  lesion.  It  has  never  exceeded 
105°  in  any  one  of  the  appended  series  of  five  hundred  cases 
which  terminated  in  recovery,  and  it  has  only  exception- 
ally attained  to  that  degree.  This  may  be  regarded  as  the 
practical  if  not  the  absolute  limit  of  temperature,  in  this  class 
of  injuries,  consistent  with  the  recovery  of  the  patient.  A 
sudden  rise  in  temperature  late  in  the  progress  of  a  case, 
or  a  continued  subnormal  temperature  at  any  time  after 
reaction  from  primary  shock,  is  always  reason  for  appre- 
hension. 

The  pulse  and  respiration  have  less  significance  as  re- 
gards the  result.  A  failure  of  cardiac  force  when  it  occurs 
is  neither  more  nor  less  threatening  in  this  than  in  other 
forms  of  disease  or  traumatism.     In  general,  the  normal. 


PROGNOSIS.  203 

or  full  and  moderately  infrequent  pulse,  is  equally  charac- 
teristic in  fatal  as  in  recovering  cases,  and  the  want  of 
symmetry  in  opposite  radial  pulsations  has  no  evident 
bearing  upon  prognosis.  The  respiration  does  not  usually 
reflect  the  degree  of  danger,  except  in  primary  shock  and 
toward  the  close  of  the  case,  when  it  corresponds  with  the 
acceleration  of  the  pulse.  An  irregularity  of  respiratory 
rhythm  indicates  a  dangerous  intracranial  pressure,  and  an 
extreme  infrequency  of  the  respiratory  act  makes  probable 
a  fatal  compression  of  the  medulla. 

Aside  from  pulse  and  temperature,  symptoms  become 
prognostic  only  as  they  determine  the  nature  and  extent 
of  the  lesions  from  which  they  result.  In  this  way  they 
are  indirectly  indicative  of  the  degree  of  danger  which  im- 
pends. A  high  temperature  or  a  rapid  and  feeble  pulse  is 
in  itself  alarming,  whatever  its  specific  intracranial  cause, 
but  the  occurrence  of  convulsions  or  the  loss  of  faecal  or 
urinary  control  is  of  grave  import  only  so  far  as  it  can  be 
connected  with  a  lesion  of  dangerous  extent  or  situation. 
The  prognosis,  like  the  diagnosis,  thus  becomes  largely 
dependent  upon  the  massing  of  symptoms  and  the  study 
of  their  mutual  relations;  and  this  again,  as  was  said  of 
diagnosis,  is  rather  a  matter  of  surgical  sagacity  and  ex- 
perience than  of  formal  rule.  There  is  no  class  of  injuries 
in  which  the  issue  is  at  all  times  so  uncertain,  and  often 
so  surprising.  The  cases  which  in  their  earlier  days  pre- 
sent the  mildest  symptoms,  and  seem  most  surely  destined 
to  unobstructed  recovery,  may  at  some  later  period  as- 
sume a  threatening  or  alarming  character  and  perhaps 
prove  fatal  in  the  end ;  as  others,  in  which  the  combination 
of  symptoms  long  justifies  the  gravest  apprehension,  may 
eventually  terminate  not  only  with  the  preservation  of  life 


204  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

but  with  perfect  restoration  of  long  disordered  or  sus- 
pended function.  There  are  evident  lesions  so  extensive, 
or  it  may  be  symptoms  so  clearly  decisive,  that  a  fatal 
event  is  unquestionable ;  but  no  conditions  can  be  so  favor- 
able as  to  assure  recovery.  The  prognosis  must  be  in 
general  not  only  guarded,  but  subject  to  revision  from  day 
to  day,  until  all  direct  symptoms  have  disappeared,  and 
temperature  has  been  for  a  length  of  time  practically 
normal. 

SECONDARY    INFLAMMATIONS. 

I.  Arachnitis. 

The  tabulation  of  recovering  cases  includes  no  in- 
stance of  arachnitis.  It  is  not  meant  to  assume  that  none 
existed,  but  that  none  could  be  diagnosticated  with  that 
degree  of  certainty  which  is  essential  for  statistical  infer- 
ence. There  were  cases  in  which  some  degree  of  menin- 
geal inflammation  was  more  than  suspected,  and  in  which 
the  possibility  of  its  confirmation  was  fortunately  avoided. 
It  may  be  be  held  as  a  correct  generalization  that  in 
arachnitis  the  certainty  of  an  unfavorable  result  is  pro- 
portionate to  the  certainty  of  diagnosis.  The  acute  or 
pyogenic  arachnoid  inflammations,  whether  simple  or  in- 
fectious, have  probably  an  always  fatal  issue;  the  sub- 
acute inflammations,  in  which  the  effusion  is  serous  or 
sero-fibrinous,  may  as  probably  be  sometimes  arrested  in 
their  course,  but  usually  at  an  early  period,  while  the  in- 
dications are  still  of  doubtful  significance.  Under  such 
circumstances  the  comparative  danger  of  the  disease  as 
it  affects  the  base  or  vertex  is  scarcely  of  importance. 


PROGNOSIS. 


205 


2.  Abscess. 

The  termination  of  central  abscess  of  the  brain  in 
death,  unless  avoided  by  operative  interference,  which  is  a 
recognized  necessity  of  idiopathic  cases,  is  no  less  inevi- 
table in  those  which  follow  violence.  The  meagre  chances 
of  recovery  after  the  absess  has  been  discovered  and  evac- 
uated are  certainly  not  increased  by  the  fact  of  a  traumatic 
origin.  The  limited  superficial  suppuration  which  results 
from  the  neglect  and  infection  of  an  external  wound,  and 
from  the  extension  of  the  suppurative  process  to  the  cerebral 
surface,  is  amenable  to  control  unless  relief  has  been  too  long 
delayed.  The  three  cases  of  central  and  one  of  superficial 
suppuration  included  in  the  appended  general  series  of 
cases  suggest  no  modification  of  these  axiomatic  state- 
ments. 


chapter   VI. 


PRINCIPLES   OF   TREATMENT. 

DIRECT   LESIONS. 

The  manner  of  treatment  is  of  importance  in  only  a 
minority  of  cases,  since  many  subjects  of  intracranial  in- 
jury are  fated  to  die  whatever  measures  may  be  adopted 
for  their  relief,  and  a  still  greater  number  are  destined  to 
recover  though  left  entirely  to  the  resources  of  nature. 
In  those  which  remain  the  result  will  often  directly  de- 
pend upon  the  assiduity  or  discretion  of  the  surgeon.  It 
is  probable  that  in  by  far  the  larger  proportion  of  cases  in 
which  the  issue  is  determined  by  treatment  it  is  met 
in  the  initial  stage,  and  by  insuring  restoration  from  pri- 
mary shock.  For  the  accomplishment  of  this  purpose  the 
exercise  of  assiduous  care  is  especially  demanded ;  the 
methods  and  agents  of  procedure  are  not  peculiar,  and 
are  too  authoritatively  prescribed  to  permit  the  use  of  any 
extraordinary  discretion.  At  a  later  period,  the  question 
of  operation  may  require  for  its  determination  the  exer- 
cise not  only  of  the  highest  surgical  discretion  but  also  of 
the  nicest  diagnostic  discrimination. 

The  collapse  from  general  shock  may  be  nearly  com- 
plete, but  such  a  condition  is  never  to  be  regarded  as  so 
far  hopeless  as  to  justify  the  neglect  of  restorative  meas- 
ures, unless  the  visible  evidences  of  a  fatal  crushing  injury 
are  .so  positive  as  to  afford  no    possible  room    for  doubt. 


PRI>XIPLES    OF   TREATMENT.  20/ 

The  rapid  ambulance  system  which  has  been  so  generally 
established,  and  the  hypodermic  use  not  only  of  alcohol 
but  also  of  the  concentrated  cardiac  stimulants,  have  made 
possible  such  immediate  and  efficient  general  stimulation  in 
cases  of  urgent  necessity  as  materially  to  reduce  the  early 
mortality  in  this  as  well  as  in  all  other  forms  of  dangerous 
traumatism.  In  doing  this  these  agencies  have  bettered  the 
apparent  numerical  prognosis  of  intracranial  injuries,  since 
concurrent  general  shock  has  so  often  proved  fatal  when  the 
essential  lesion  was  far  from  irremediable.  It  is  scarcely 
necessary  in  a  work  of  this  character  to  refer  in  detail  to 
the  means  employed  to  establish  reaction.  The}^  include 
the  usual  medicinal  agents  for  cardiac  stimulation,  as  digi- 
talis, glonoin,  and  strychnine,  and  when  the  lesion  is 
largely  destructive  or  much  blood  has  been  lost  their  use 
may  be  necessitated  for  an  indefinite  time  after  nervous 
force  has  been  restored.  The  resort  to  these  reactive 
measures,  when  indicated,  will  take  precedence  of  others 
for  the  direct  relief  of  the  intracranial  injury.  There  are 
instances,  however,  in  which  the  persistence  of  external, 
or  even  of  intracranial  hemorrhage,  or  of  some  other  acces- 
sible pathic  conditions,  prolongs  or  intensifies  existing 
shock,  and  may  require  concurrent  treatment. 

General  reaction  and  the  re-establishment  of  a  compar- 
atively normal  pulse  and  temperature  should  be  followed 
by  the  earliest  possible  attention  to  cranial  and  intracranial 
lesions.  The  first  step  to  be  taken,  in  all  but  the  obviously 
trivial  cases,  is  the  shaving  of  the  head,  as  a  measure  at 
once  diagnostic  and  therapeutic.  Its  importance  in  diag- 
nosis as  a  means  of  ascertaining  the  presence  or  absence 
of  fracture,  or  the  existence  of  otherwise  inappreciable 
contusions,    has  been  previously  noted;  its  value  in  the 


208  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

treatment  of  intracranial  injuries  will  be  considered  later. 
The  propriety  of  incision,  if  further  necessary  to  the  abso- 
lute determination  of  the  question  of  fracture,  has  also  been 
made  evident ;  and  the  principles  which  govern  the  man- 
agement of  the  cranial  wound,  and  the  details  of  their  ap- 
plication to  particular  cases,  have  been  formulated  in  a 
previous  chapter.  It  is  in  cases  of  intracranial  lesion  with- 
out implication  of  the  cranial  wall  that  new  problems  of 
treatment  arise,  and  that  the  advisability  of  operative  in- 
terference must  be  reconsidered  in  the  presence  of  new 
conditions. 

An  operation  then  ceases  to  be  confined  to  the  possible 
removal  of  already  detached  or  depressed  cranial  frag- 
ments, or  to  be  made  only  in  fulfilment  of  an  obvious 
indication  in  treatment.  It  is  always  an  invasion  of  a 
heretofore  unbroken  osseous  barrier,  in  pursuance  of  the 
dictates  of  a  judgment  which  can  never  be  infallible,  and 
is  therefore  to  be  less  lightly  undertaken.  It  is  not  like 
the  incision  of  the  scalp,  justifiable  as  a  purely  explorative 
procedure,  which  at  the  worst  is  nugatory  if  the  result 
proves  it  to  have  been  unnecessary.  If  in  some  degree  ex- 
plorative, it  must  still  have  sufficient  logical  basis  to  justify 
the  risk  attendant  upon  any  operative  interference  at  the 
time  and  under  the  circumstances  which  will  exist  when 
it  is  most  likely  to  be  brought  in  question.  The  one  in- 
tracranial lesion  for  the  relief  of  which,  when  clearly 
diagnosticated,  it  is  fully  conceded  that  operation  may  be 
justified  or  demanded,  is  epidural  hemorrhage.  The  time 
of  election  for  interference  will  be  after  the  establishment 
of  full  or  of  partial  reaction,  as  the  extravasation  is  be- 
lieved to  have  ceased,  or  to  be  still  in  progress  after  an 
interval  limited  in  duration  by  the  judgment  of  the  sur- 


PRINCIPLES    OF   TREATMENT.  2O9 

geon.  The  judicious  resort  to  operation  in  the  treatment 
of  this  form  of  hemorrhage  is  vindicated  both  by  results 
and  by  the  observation  of  cases  and  necropsies  in  which  it 
has  been  neglected.  Success  will  be  commensurate  with 
accuracy  of  diagnosis  and  with  justness  of  appreciation  of 
the  time  and  conditions  when  interference  is  demanded. 
It  is  fortunate  that  the  diagnostic  indications  are  often 
most  distinct  in  this  one  of  the  intracranial  lesions  best 
fitted  for  operative  relief.  It  is  the  form  of  hemorrhage 
in  which,  with  or  without  primary  unconsciousness,  an  in- 
terval of  consciousness  most  frequently  precedes  its  later 
loss.  It  is  also  the  one  in  which  the  dilatation  of  the  cor- 
responding pupil  is  most  characteristic,  especially  in  the 
absence  of  the  temperature  and  other  conditions  of  general 
contusion  ;  and  the  one  in  which  gradually  and  perceptibly 
increasing  paralysis  of  the  extremities,  and  more  or  less 
rapidly  progressive  stupor  ending  in  coma,  are  most  often 
observed.  The  moderately  increased  or  diminished  tem- 
perature, the  contusion  or  haematoma,  or  the  cranial  fissure 
in  the  vicinage  of  the  larger  middle  meningeal  branches, 
and  other  symptoms  which  in  themselves  or  in  connection 
with  others  mentioned  may  be  considered  diagnostic,  it 
is  needless  to  recapitulate.  The  diagnosis  ought  to  be 
usually  practicable  in  cases  sufficiently  uncomplicated  to 
warrant  the  contemplation  of  a  possible  operation. 

The  decision  as  to  the  necessity  or  futility  of  operative 
interference,  which  may  be  one  of  the  most  difficult  ques- 
tions in  intracranial  surgery  to  decide,  will  often  require 
the  exercise  of  great  discretion,  inspired  by  much  knowl- 
edge derived  from  experience  and  directed  by  the  soundest 
judgment.  Three  considerations  will  present  themselves: 
the  contraindications  which  may  exist  in  the  influence  of 
14 


2IO  INJURIES   OF   THE    BRAIN    AND    MEMBRANES. 

allied  lesions ;  the  probable  necessity  for  intervention ;  and 
the  exact  time  at  which  operation  should  be  done. 

If  other  intracranial  injuries  have  been  sustained  which 
are  obviously  or  presumably  of  immediately  fatal  charac- 
ter, operation  will  probably  hasten  rather  than  retard  the 
catastrophe,  though  it  may  confirm  the  diagnosis.  The 
indications  of  severe  diffuse  contusion  or  of  extensive 
laceration  of  the  brain,  added  to  the  evidence  of  hemor- 
rhage in  sufficient  amount  to  suggest  an  exploration  of  the 
cranial  cavity,  constitute  a  general  condition  which,  if  not 
absolutely  hopeless,  is  ill  calculated  to  withstand  the  in- 
fliction of  further  injury.  The  slender  chances  of  recovery 
will  be  better  conserved  by  inaction.  It  is  only  when 
symptoms  point  clearly  to  hemorrhage  as  the  essential  if 
not  the  exclusive  lesion  that  operation  for  its  relief  will 
afford  legitimate  hope  of  success. 

If  the  existence  of  a  comparatively  uncomplicated  epi- 
dural hemorrhage  of  considerable  extent  seems  to  have 
been  established  by  the  study  of  symptoms,  the  necessity 
or  propriety  of  attempting  its  removal  by  operative  means 
will  consecutively  demand  consideration.  The  questions 
involved  are  theoretically  simple:  whether  the  constitu- 
tional condition  of  the  patient  will  permit  interference; 
and  whether  the  amount  of  extravasation  and  its  inhibitory 
effect  upon  cerebral  function  are  so  far  limited  as  to  render 
its  eventual  disappearance  by  absorption  possible  or  even 
probable.  The  solution  of  these  problems  is  often  easily 
reached ;  reaction  may  never  occur,  or,  after  it  has  become 
complete,  the  persistence  or  increasing  gravity  of  pressure 
symptoms  may  positively  indicate  the  danger  of  a  con- 
tinued expectancy  in  treatment.  There  are  still  other 
cases,  in  which  reaction  is  in  some  degree  unsatisfactory, 


PRINCIPLES    OF    TREATMENT.  211 

or  in  which  the  value  of  symptoms  is  indeterminate;  a 
decision  must  then  in  each  instance  rest  solely  upon  the 
discretion  of  the  sugeon ;  no  formal  rules  can  be  prescribed 
which  should  control  his  judgment  or  guide  his  action. 

If  operation  is  to  be  done,  the  time  which  is  chosen 
for  its  performance  may  practically  determine  its  result. 
Hasty  and  ill-considered  action,  or  a  lack  of  promptitude 
at  the  opportune  moment,  may  end  in  equal  disaster.  The 
cases  in  Avhich  reaction  entirely  fails,  or  in  -which  pulse, 
temperature,  and  external  warmth  are  perfectly  restored, 
while  with  the  lapse  of  time  pressure  symptoms  deepen  or 
remain  profound,  can  hardly  occasion  doubt  as  to  the 
direction  in  which  duty  lies ;  but  when  with  imperfect 
reaction  these  symptoms  are  still  progressive,  opportunity 
must  be  seized  when  the  tide  is  at  its  full,  when  reaction 
has  reached  its  limit,  and  before  recession  of  strength  be- 
gins, in  order  to  profit  by  whatever  slender  chance  there 
may  be  for  a  favorable  issue.  Success  may  be  doubtful  at 
the  best,  but  any  waste  of  vital  force  invites  certain  failure. 
It  will  not  often  happen  that  the  fundamental  rule  in  sur- 
gery, that  operation  should  always  be  deferred  till  after 
reaction  has  been  fully  established,  should  be  violated; 
never  in  this  instance  by  reason  of  the  gravity  of  pathic 
indications,  or  when  reaction  fails  almost  at  its  beginning; 
but  only  when,  after  a  time,  with  some  fair  degree  of 
strength,  coma  deepens  and  the  pulse  grows  weaker,  as 
hemorrhage  still  goes  on.  In  the  exceptional  case,  opera- 
tion must  always  be  early,  as  it  always  will  be  by  choice, 
if  done  when  hemorrhage  has  ceased  and  reaction  has  be- 
come complete;  but  the  patient  sometimes  escapes  obser- 
vation till  some  days  have  passed  and  operative  conditions 
may  yet  remain  propitious. 


212  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

The  resort  to  operation  in  other  forms  of  direct  intra- 
cranial lesion  is  of  very  limited  utility.  Definite  indica- 
tions which  can  be  met  by  operative  measures  are  usually 
wanting,  and  in  their  absence  an  invasion  of  the  cranial 
cavity  must  be  empirical  and  without  justification.  The 
conditions  which  when  recognized  might  be  supposed  to 
encourage  this  procedure  are  usually  complicated  by  oth- 
ers which  render  it  futile.  The  occurrence  of  subdural 
hemorrhage  or  of  serous  effusion  from  meningeal  contusion 
occasions  dangerous  cerebral  compression,  and  operation 
might  be  considered  practicable  and  efficacious,  as  it  is  in 
epidural  extravasation;  and  a  pial,  mistaken  for  an  epi- 
dural, hemorrhage  has  in  some  instances  been  successfully 
treated  in  this  manner.  Such  an  operation,  however, 
when  premeditated,  is  without  adequate  reason  and  can 
afford  no  just  expectation  of  success.  The  epidural  clot  is 
usually  of  limited  area,  and  can  be  wholly  removed,  or  in 
sufficient  degree  to  avert  danger  until  the  remainder  has 
suffered  absorption.  The  pial  or  cortical  hemorrhage,  if  in 
recognizable  amount,  will  be  widely  diffused,  and  so  en- 
tangled in  the  meshes  of  the  pia  that  little  can  escape  or 
be  withdrawn  through  the  cranial  opening.  The  dropsical 
effusion  which  follows  the  meningeal  lesion,  if  its  exist- 
ence could  be  positively  known  or  reasonably  inferred, 
might  doubtless  be  drained  through  this  perforation.  The 
further  and  fundamental  fact  which  contraindicates  and 
makes  fruitless  the  attempt  to  afford  relief  by  the  removal 
of  these  subdural  accumulations  is  that  the  essential  lesion 
remains  unaffected.  The  pial  hemorrhage  or  serous  effu- 
sion which  results  from  a  meningeal  contusion  will  prob- 
ably be  associated  with  a  like  condition  of  the  entire  brain 
substance,  and   the  cortical  hemorrhage  will  be  no  more 


PRINCIPLES    OF   TREATMENT.  213 

than  an  incident  of  the  laceration  from  which  it  is  de- 
rived. The  added  traumatism  of  the  operation  will  thus 
be  uncompensated  by  any  possible  betterment  of  conditions 
which  depend  upon  the  more  important  structural  altera- 
tions produced  by  the  original  injury.  The  shock  which 
attends  any  operative  procedure,  and  which  under  favor- 
able conditions  may  be  unimportant  when  the  cranial  wall 
is  alone  involved,  is  always  of  more  serious  concern  when 
the  dura  mater  is  incised  and  the  cerebral  surface  exposed. 
If,  as  in  the  cases  considered,  nutritive  changes  in  the 
intracranial  tissues  already  exist,  this  danger  is  still  further 
exaggerated,  and  must  be  taken  clearly  into  account  when- 
ever under  such  circumstances  so  radical  a  measure  may  be 
contemplated. 

In  the  history  of  one  of  the  appended  cases  there  is  a 
record  of  a  result  obtained  by  trephination,  suggesting  a 
possible  indication  for  operation,  which  may  be  stated  with 
some  reserve.  In  this  instance,  in  which  an  apoplectic 
effusion  was  followed  by  a  traumatic  cerebellar  laceration, 
the  patient  was  paralyzed,  anaesthetic,  and  profoundly  un- 
conscious. He  was  trephined  and  a  large  amount  of 
serous  fluid  drained  from  the  surface  of  the  brain.  His 
temperature  fell  in  six  hours  from  103.4°  to  98.6°.  He 
became  conscious,  could  articulate,  spoke  rationally  and 
intelligently,  gave  his  name  and  address,  again  lapsed 
into  unconsciousness,  and  fourteen  hours  later  died.  The 
transient  return  to  consciousness  was  in  this  case  wholly 
unimportant,  but  it  involves  possibilities  of  startling  medico- 
legal interest.  It  is  not  unusual  for  the  victim  of  a  homi- 
cidal assault  to  remain  unconscious  till  his  death,  and  that 
the  criminal  escapes  in  the  absence  of  any  witness  of  his 
crime.     If  such  a  coma  can  be  reasonably  ascribed  to  a 


2  14  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

fluid  compressing  the  brain,  even  though  complicated  by 
fatal  lesion  of  its  parenchyma,  trephination,  it  is  evident, 
may  at  least  by  a  possibility  temporarily  restore  conscious- 
ness, intelligence,  and  speech,  to  the  furtherance  of  the 
ends  of  justice.  The  prospect  of  realizing  this  success 
would  certainly  be  not  altogether  chimerical,  for  in  the 
instance  cited  just  such  a  hypothetical  result  was  absolutely 
attained.  The  question  of  operation  is  not  to  be  decided 
upon  any  ground  foreign  to  the  welfare  of  the  patient ;  but 
when  death  seems  inevitable  and  doubt  exists  as  to  the 
propriety  of  interference,  medico-legal  considerations  are 
recognized  as  having  a  certain  degree  of  weight.  It  has 
sometimes  happened,  when  homicidal  injury  has  proved 
fatal,  that  the  attempt  has  been  made  to  transfer  responsi- 
bility from  the  murderer  to  the  surgeon,  who  in  his  discre- 
tion has  resorted  to  operation,  or  perhaps  even  found  occa- 
sion for  the  administration  of  narcotics.  This  hazard,  and 
the  necessity  of  self-protection  which  it  involves,  are  very 
properly  held  in  view  when  professional  duty  permits; 
the  acceptance  of  the  same  principle  may  equally  justify, 
if  occasion  arises,  a  due  regard  for  the  interests  of  justice, 
within  the  limits  established  by  conscience  and  sound 
judgment.  The  contingency  is  remote,  but  it  is  still  pos- 
sible. 

There  can  be  no  advantage  from  operation  when  the 
urgent  symptoms  are  the  result  of  a  general  cerebral  contu- 
sion. As  an  underlying  condition  of  minor  importance 
contusion  may  not  contraindicate  an  operation  otherwise 
made  necessary;  but  in  itself,  or  as  it  approximates  a  para- 
mount lesion,  it  is  obviously  beyond  the  scope  of  any 
measure  of  mechanical  relief.  It  is  scarcely  necessary  to 
point  out  its  impossible   application  to  cases  of  this  char- 


PRINCIPLES    OF   TREATMENT,  21 5 

acter,  in  which  existent  pressure  is  intracerebral  and 
diffuse,  and  incapable  of  mitigation  by  any  practicable  re- 
moval of  the  cranial  wall;  and  in  which,  moreover,  the 
morbid  state  is  essentially  one  of  nutritive  change  in  which 
interstitial  pressure  is  merely  incidental. 

The  operative  treatment  of  brain  lacerations,  as  they 
occur  at  points  remote  from  the  seat  of  fracture  of  the 
cranial  vertex,  might  have  the  pathological  warrant  which 
in  the  general  lesion  is  lacking,  if  its  employment  were 
practicable.  Superficial  lacerations  of  the  vertex  in  con- 
nection with  fracture  are  accessible,  and,  when  drained  and 
maintained  in  an  aseptic  condition,  are  usually  cicatrized 
without  serious  danger  to  the  patient.  There  is  no  evi- 
dent reason  why  cerebral  wounds  which  occur  without 
cranial  injury  should  not  be  as  amenable  to  local  treat- 
ment, if  they  could  be  reached;  but  they  are  often  central, 
and,  if  superficial,  very  likely  to  be  situated  in  some  inac- 
cessible region  of  the  base.  The  impossibility  of  accurate 
localization  of  the  lesion,  in  the  vast  majority  of  cases,  by 
any  known  diagnostic  methods  is  additionally  a  bar  to  any 
justifiable  attempt  at  topical  treatment  by  operative  means. 
It  is  still  a  question,  beyond  that  of  feasibility,  how  far 
operation  if  made  possible  might  increase  the  chances 
of  recovery.  In  general,  laceration  as  disclosed  in  post- 
mortem examination,  except  when  enormous  excavation 
has  been  produced  by  the  attendant  hemorrhage,  is  com- 
plicated by  diffuse  cerebral  contusion  which  is  largely  re- 
sponsible for  the  fatal  result.  In  a  minorit}''  of  cases  the 
cerebral  wounds  may  be  found  to  be  in  a  septic  condition, 
and  it  is  in  these,  if  their  exact  position  could  have  been 
determined  and  exposed,  that  a  possible  danger  might 
have  been  averted.     Altogether  there  seems  little  to  be 


2l6  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

hoped  for  in  these  cases,  now  or  prospectively,  from  any 
operative  interference. 

It  has  been  proposed  to  treat  arachnitis  by  perforation 
of  the  cranial  wall,  and  withdrawal  of  the  inflammatory 
effusion ;  and  this  method  of  treatment,  it  has  been 
claimed,  has  been  followed  by  good  results.  It  is  difficult 
to  understand  what  permanent  advantage  can  be  derived 
from  the  removal  of  an  effect  while  the  cause  remains 
operative.  The  elevation  of  depressed  bone  is  a  radical 
measure  of  relief,  because  with  the  removal  of  the  source 
of  symptoms,  the  possibility  of  their  continuance  or  recur- 
rence is  removed  ;  and  the  extraction  of  an  epidural  clot  is 
made  effective  by  the  ligation,  if  necessary,  of  the  ruptured 
vessel ;  but  the  mere  drainage  of  an  inflammatory  arachnoid 
effusion  will  by  no  means  prevent  its  return.  There  is  no 
reason  to  believe  that  a  diminution  of  the  pressure  exerted 
by  a  serous  exudation  will  lead  to  the  cessation  of  the 
pathic  processes  upon  which  it  depends;  it  is  not  conso- 
nant with  what  is  observed  elsewhere  when  no  obstacle 
exists  to  the  escape  of  inflammatory  exudations.  In  trau- 
matic cases,  at  least,  it  is  not  the  increase  of  intracranial 
pressure  which  proves  fatal,  but  the  direct  irritant  and  de- 
pressing effect  of  the  tissue  changes  which  characterize 
the  inflammatory  process.  So  far  as  the  effusion  is  plastic 
or  purulent,  drainage  will  be  impossible  or  very  imperfect, 
whether  it  be  attempted  from  the  Sylvian  or  post-erior  cer. 
vical  region,  or  elsewhere,  and  no  semblance  of  advantage 
can  be  expected  to  accrue.  The  views  of  Gross,  which 
have  been  held  to  favor  trephination  and  drainage  in  cases 
of  traumatic  arachnitis,  are  evidently  founded  upon  the 
observance  of  limited  purulent  accumulations  in  the  arach- 
noid cavity,  and  resulting  from  a  now  infrequent  form  of 


PRINCIPLES    OF   TREATMENT.  217 

pachymeningitis ;  they  have  no  reference  to  a  true  arach- 
nitis in  which  the  effusions  are  subarachnoid  and  diffuse, 
and  which  is  meant  to  be  understood  when  the  term  men- 
ingitis is  employed.  Macewen's  instances  of  recovery  from 
purulent  basilar  meningitis  after  operation  were  secondary 
to  inflammation  of  the  middle  ear,  and  were  apparently 
recognized  by  him  as  limited.  The  advocacy  by  Ruth  of 
this  method  of  treatment  is  not  supported  by  a  record  of 
answerable  cases.  It  is  doubtful  if  any  properly  authenti- 
cated instance  can  be  adduced  in  which  a  diffuse  inflam- 
matory subarachnoid  exudation  has  been  drained  with  sub- 
stantial benefit  to  the  patient.  It  seems  probable  that  in 
some  cases  subarachnoid  oedema  has  been  mistaken  for  a 
product  of  inflammation.  A  case  reported  by  McCosh  was 
undoubtedly  one  of  arachnitis,  possibly  diffuse,  and  though 
recovery  was  regarded  as  nearly  complete  in  the  third 
month,  the  patient  was  then  the  subject  of  a  forming  cere- 
bral abscess,  from  which  he  died  some  time  subsequent  to 
an  operation  for  its  relief.  The  record  of  necropsy  does  not 
make  clear  the  relation  which  existed  between  the  super- 
ficial and  deep  inflammatory  lesions,  but  it  is  probable,  from 
the  conditions  observed  when  the  abscess  was  evacuated, 
that  they  were  connected.  This  case  was  brilliant  in  diag. 
nosis  and  operation  in  both  its  early  and  later  stages,  but  it 
is  at  least  not  conclusive  as  to  the  extent  of  cure  of  the 
arachnitis. 

The  justifiable  use  of  operation  in  head  injuries  is  thus 
seen  to  be  very  limited.  It  may  be  summarized  as  prop- 
erly general  in  depressed  cranial  fractures,  frequent  in 
comparatively  uncomplicated  epidural  hemorrhages,  and 
exceptional  in  subdural  lesions  whether  of  the  brain  or  of 
the    pio-arachnoid  membrane.      The    resort  to  operative 


2l8  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

measures,  which  is  essential  under  favorable  constitutional 
conditions  in  abscess  of  the  brain  and  in  intracranial  gun- 
shot wounds,  will  be  given  consideration  in  the  later  study 
of  those  conditions.  If  in  the  general  class  of  intracranial 
injuries  operation  is  to  be  but  infrequently  done,  the  ques- 
tion of  operation  will  be  often  raised  and  decision  as  to 
the  course  to  be  pursued  will  then  entail  grave  responsi- 
bility, since  error  in  judgment  may  deprive  the  patient  of  a 
chance  for  life  by  increasing  the  danger  of  an  already  criti- 
cal condition.  Action  or  inaction  at  the  wrong  moment 
has  invited  disaster  on  either  hand ;  but  instances  of  too 
early  or  unwarranted  operative  interference  by  inexperi- 
enced surgeons  outnumber  those  in  which  the  ultra-con- 
servatism of  their  elders  has  led  to  a  perhaps  fatal  neglect. 
The  acceptance  or  rejection  of  operation  as  a  method 
of  treatment,  when  encephalic  lesions  are  independent  of 
accessible  cranial  fracture,  is  to  be  decided  in  each  instance 
upon  specific  and  tenable  grounds.  Operation  is  not  to  be 
done  as  a  so-called  last  resource,  and  because  the  patient 
is  likely  or  sure  to  die  without  it,  as  he  is  with  it  unless 
some  blind  chance  interposes  where  reason  affords  no  room 
for  hope.  Intracranial  exploration  will  be  defensible  or 
indefensible  as  it  is  made  with  or  without  sufficient  cause, 
and  not  as  it  may  conform  to  an  opinion  deducible  from  a 
wide  generalization  of  results  that  it  is  a  good  or  a  bad 
procedure.  Unless  general  rules  can  be  made  absolute,  the 
obligation  to  determine  in  each  instance  the  treatment  to 
be  pursued  in  accordance  with  the  indications  which  it  pre- 
sents remains  unimpaired,  and  the  contention  that  more 
lives  are  lost  by  operative  interference  which  is  unneces- 
sary than  by  its  neglect  when  it  is  required  has  no  relation 
to  the  exigencies  of  particular  cases.     The  failure  to  recog- 


PRINCIPLES    OF   TREATMENT.  219 

nize  the  truth  of  these  apparently  simple  propositions  ac- 
counts for  the  widely  divergent  practice  which  has  obtained 
in  different  countries  at  corresponding  or  at  different 
times.  The  record  of  ten  years  in  which  only  four  trephi- 
nations were  reported  in  France,  while  during  the  same 
period  one  hundred  and  fifty-seven  were  reported  in  Eng- 
land (Dennis) ,  is  scarcely  explicable  except  upon  the  sup- 
position that  treatment  was  ordered  in  accordance  with 
conventional  general  rules,  and  not  with  a  regard  to  special 
indications.  The  character  of  the  discussion  which  is  still 
maintained  as  to  the  merits  of  trephination  necessitates 
the  placing  of  some  emphasis  upon  this  phase  of  the 
subject. 

There  are  late  results  of  intracranial  traumatism  in 
which  the  indications  for  treatment  are  to  be  considered  as 
those  of  a  separate  class  of  cases,  distinct  from  recent  in- 
juries. These  include  paralyses  and  convulsions  which  are 
often  due  to  the  imperfect  absorption  of  surface  hemor- 
rhages, or  to  superficial  or  ventricular  effusion  from  an 
original  contusion.  The  case  of  drainage  of  a  lateral  ven- 
tricle with  subsequent  recovery  of  the  patient,  reported  by 
McCosh,  was  probably  of  this  nature ;  the  historical  details 
and  the  absence  of  superficial  effusion  seem  to  disprove 
the  inflammatory  character  of  the  disease,  in  which  the 
subarachnoid  and  interstitial  oedema  of  a  general  menin- 
geal and  cerebral  contusion  might  have  readily  disap- 
peared, while  the  ventricular  serous  accummulation  re- 
mained and  increased.  One  of  the  cases  reported  by  Ruth 
seems  as  probably  to  have  been  an  instance  of  superficial 
serous  transudation  from  meningeal  contusion.  A  purely 
explorative  examination  of  the  cranial  contents  is  not  only 
justified  but  demanded  when  such  permanent  functional 


220  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

derangements  succeed  the  primary  effects  of  intracranial 
injury.  The  hazard  of  operation  is  minimized  at  this 
time,  and  if  the  hope  of  success  is  not  realized  even  though 
an  evident  lesion  is  discovered,  the  patient's  condition  is 
not  likely  to  be  made  worse. 

The  possibility  of  danger  in  the  procedure  may  or  may 
not  be  a  factor  to  be  considered  in  deciding  upon  the 
advisability  of  operation.  No  such  question  can  arise 
in  connection  with  the  elevation  of  depressed  bone  ;  and  in 
the  removal  of  foreign  bodies  from  the  brain,  or  of  an 
epidural  clot  from  the  cranial  cavity  less  danger  is  in- 
curred than  is  involved  in  the  continuance  of  the  morbid 
condition  which  it  is  sought  to  remedy.  It  is  in  the 
treatment  of  the  subdural  lesions,  in  which  advantage  is 
most  problematical,  that  the  operation  is  in  itself  the 
source  of  new  and  serious  peril.  It  is  usually  a  question 
of  secondary  interference,  when  conditions  are  always 
unfavorable,  and  the  brain,  which  is  necessarily  exposed 
and  in  which  morbid  structural  changes  are  in  progress,  is 
especially  prone  to  resent  disturbance.  The  prospect  of 
success  in  meeting  the  indication  is  in  general  remote ;  and 
the  danger  to  be  incurred  is  so  considerable  and  so  immi- 
nent that  ordinarily  it  may  well  suffice  to  negative  any 
measure  of  this  character.  If  at  the  outset,  with  urgent 
symptoms  of  hemorrhage,  the  cranial  cavity  is  opened  and 
the  extravasation  is  found  to  be  pial,  and  perhaps  involv- 
ing the  arachnoid  cavity,  the  conditions  will  approximate 
those  of  epidural  hemorrhage,  for  which  it  has  been  pos- 
sibly mistaken,  and  the  prognosis  will  not  be  materially 
worse  than  with  the  more  superficial  lesion.  The  cases  in 
which  operation  may  be  indicated  for  the  relief  of  symp- 
toms existing  at  the  end  of  weeks  or  months  are  not  anal- 


PRINCIPLES   OF   TREATMENT.  221 

ogous  to  others  which  have  been  considered,  and  have 
been  already  placed  in  a  distinct  category.  These  are  not 
more  properly  secondary  than  they  are  primary  operations, 
as  those  terms  are  employed,  but  in  this  sense  are  entirely 
disconnected  with  the  original  injury ;  and,  even  though 
the  brain  substance  is  invaded,  the  danger  of  interference 
is  less  to  be  dreaded  than  when  it  is  more  closely  related 
in  time  to  the  application  of  violence.  If,  however,  atten- 
tion be  confined  to  the  traumatisms  of  the  subarachnoid 
structures,  in  which  after  the  lapse  of  hours  or  days  the  in- 
crease in  the  severity  of  symptoms  and  the  growing  hope- 
lessness of  non-operative  means  of  relief  incite  the  surgeon 
to  attempt  an  operation,  the  danger  it  entails  as  contrasted 
with  the  meagre  promise  it  offers,  cannot  well  be  ignored. 
The  field  of  operation  is  restricted,  but  the  indications 
for  interference  when  they  exist  are  positive,  and  what- 
ever degree  of  danger  must  be  encountered  is  to  be  mini- 
mized by  the  most  scrupulous  care  exercised  in  the  choice 
of  time  and  circumstance  and  of  technical  detail.  The 
necessity  of  awaiting  complete  reaction  in  primary  opera- 
tions has  been  stated  fully,  but  its  reiteration  cannot  be 
made  too  frequent.  The  single  exception,  when  imperfect 
reaction  is  followed  by  indications  of  continued  epidural 
hemorrhage,  need  not  obscure  the  vital  importance  of  the 
general  rule.  The  neglect  of  this  fundamental  law  in  the 
management  of  all  traumatisms,  whatever  may  be  its  ex- 
planation, is  probably  at  once  the  most  frequent  and  the 
most  fatal  error  of  the  inexperienced  surgeon.  If  reaction 
has  been  fully  established  and  the  indications  for  opera- 
tion are  clear,  promptitude  of  action  becomes  as  imperative 
as  was  previous  delay.  In  all  operative  cases  there  is  some 
degree  of  diffuse  cerebral  contusion,  and  with  the  occur- 


222  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

rence  of  considerable  hemorrhage  some  external  cerebral 
compression.  There  results  an  obstruction  to  cerebral 
capillary  circulation  which  renders  the  administration  of 
anaesthetics  especially  hazardous.  It  is  better,  therefore, 
in  case  of  marked  intracranial  lesion  to  avoid  their  use 
when  practicable,  and,  if  indispensable,  to  restrict  it  as  far 
as  possible.  When  the  immediate  issue  is  fatal,  the  an- 
aesthetic is  often  largely  responsible  for  the  result. 

The  general  conduct  of  operation,  and  the  management 
of  its  details  are  adequately  described  in  the  more  recent 
text-books  of  general  surgery.  The  maintenance  of  asep- 
tic conditions  is  not  less  an  absolute  necessity  than  in  ab- 
dominal section,  and  presents  no  unusual  difficulties  un- 
less the  exigencies  of  a  case  compel  immediate  interference 
under  circumstances  in  which  ordinary  appliances  are  un- 
attainable. The  loss  of  blood,  which,  from  the  conditions 
of  cerebral  circulation  is  badly  borne,  must  be  restricted 
to  the  smallest  possible  amount  by  the  exercise  of  unremit- 
ting care. 

The  immediate  purpose  of  operation  in  cases  without 
cranial  fracture  -is  to  obtain  access  to  the  cranial  cavity ; 
and  the  use  of  the  trephine  affords  in  general  the  most 
convenient  means  to  that  end.  The  further  employment 
of  the  rongeur,  chisel,  or  saw,  will  be  in  like  manner  a 
matter  of  convenience,  and  with  the  situation  and  size  of 
one  or  more  openings,  the  reimplantation  of  bone,  and 
other  practical  details,  concerns  a  phase  of  the  subject,  as 
before  stated,  sufficiently  considered  in  the  general  text- 
books. The  extent  to  which  exploration  should  be  carried 
may  be  predetermined  by  the  object  for  which  operation 
has  been  instituted,  or  it  may  require  decision  at  the 
moment  in  view  of  conditions  disclosed   in  its  progress. 


PRINCIPLES    OF    TREATMENT.  223 

In  recent  cases  it  will  not  often  be  designed  to  expose  the 
subdural  structures ;  but  if,  with  or  without  epidural  lesion, 
there  are  discoloration,  distention,  or  absence  of  pulsation 
of  the  dura  mater,  that  membrane  should  be  incised.  If 
the  removal  of  foreign  bodies  be  excepted,  it  is  only  in  the 
treatment  of  the  later  results  of  cerebral  lesions  that  the 
brain  itself  may  be  invaded,  as  it  becomes  necessary  for 
the  relief  of  ventricular  distention  or  for  the  evacuation  of 
abscess. 

The  general  management  of  primary  intracranial  in- 
juries is  limited  to  the  fulfilment  of  such  indications  as  are 
directly  afforded  by  symptoms.  The  necessity  for  the  con- 
tinuance of  general  and  specific  cardiac  stimulants  for  a 
length  of  time  after  the  establishment  of  reaction  has  been 
mentioned  in  correlation  with  the  treatment  of  primary 
shock.  The  character  of  the  pulse  is  the  sole  guide  in  de- 
termining the  period  of  their  administration,  to  which  ac- 
tive delirium,  heat  of  surface,  or  muscular  strength,  is  no 
more  a  contraindication  than  in  morbid  processes  of  a 
different  nature.  Even  in  recovering  cases  these  remedies 
may  be  requisite  for  days  or  weeks  during- the  employment 
of  more  directly  curative  measures,  to  which  they  afford 
essential  support,  or  through  a  prolonged  convalescence. 

The  shaving  of  the  head,  which  has  been  advised  as  a 
means  of  facilitating  diagnosis,  is  at  the  same  time  a  meas- 
ure of  treatment.  The  weight  and  thickness  of  the  hair, 
with  which  the  patient  is  often  favored,  increases  the  de- 
gree of  local  heat  as  it  also  prevents  its  dissipation,  and  its 
removal  in  some  degree  aids  in  the  reduction  of  tempera- 
ture. The  essential  advantage,  however,  to  be  derived 
from  this  procedure  is  that  it  permits  the  effective  applica- 
tion  of   the   ice-cap,  which   next  to  trephination,  under 


224  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

indicated  conditions,  is  most  nearly  a  directly  curative 
resource.  The  topical  use  of  cold  in  this  manner  is  ser- 
viceable in  those  cases  in  which  cerebral  hyperaemia  or 
meningeal  inflammation  is  manifested  by  pain,  high  tem- 
perature, and  active  ~  delirium.  It  is  contraindicated  in 
hemorrhages  and  cerebral  lacerations  when  uncomplicated 
by  serious  contusion ;  but,  as  those  lesions  are  constantly 
thus  complicated,  it  may  be  held  a  proper  resort  when  such 
symptoms  are  manifest,  without  regard  to  exact  diagnosis. 
The  constringence  of  congested  internal  vessels  by  the  in- 
fluence of  cold  exerted  through  the  tegumentary  coverings 
of  the  cavities  of  the  body  is  fully  recognized.  It  is  evi- 
dent in  this  class  of  cases  from  the  usual  subsidence  of  the 
symptoms  for  the  relief  of  which  it  has  been  employed; 
and  in  many  instances  the  nutritive  changes  inaugurated 
by  the  diffuse  lesion  seem  to  have  been  arrested,  and  the 
integrity  of  the  parts  restored.  There  is  the  history  of  a 
case,  among  those  appended,  which  ended  in  recovery,  in 
which  the  mind  was  clear  and  the  temperature  approxi- 
mately normal  whenever  the  ice-cap  was  applied,  and  in 
which  the  temperature  rose  markedly  and  delirium  recurred 
whenever  it  was  removed.  These  interchangeable  condi- 
tions were  made  the  subject  of  frequent  observation  for 
several  days. 

The  use  of  a  mild  form  of  mechanical  restraint  is  often 
required  for  keeping  the  patient  in  bed.  It  has  an  inci- 
dental value  in  quieting  nervous  excitement  and  husband- 
ing physical  strength,  which  is  of  even  greater  importance 
than  the  fulfilment  of  what  is  usually  regarded  as  its  pri- 
mary indication.  It  is  oftener  applied  in  consequence  of 
extreme  restlessness  or  persistent  efforts  to  rise  from  the 
bed  than  of  violent  delirium.     The  patient  rarely  objects 


PRINCIPLES    OFTREATMENT.  22$ 

to  the  confinement,  and  his  struggles  cease  almost  at  once, 
not  from  terror,  but  because  his  mental  condition  is  such 
that  he  is  easily  diverted  from  efforts  which  he  finds  to  be 
ineffectual.  The  waste  of  both  nervous  and  physical  force 
is  thus  better  prevented  than  it  could  be  by  the  adminis- 
tration of  medicinal  sedatives  and  stimulants.  Leather 
bracelets  and  a  strap  to  control  the  wrists  and  an  arrange- 
ment of  sheets  will  suffice  for  the  purpose. 

The  control  of  nervous  irritation  and  the  maintenance 
of  strength  are  the  paramount  indications  in  general  treat- 
ment. If  the  ice-cap  and  mechanical  restraint  are  insuffi- 
cient to  afford  rest  and  necessary  sleep,  or  are  unsuited  to 
the  conditions  of  the  case,  the  hypodermic  administration 
of  morphine  is  likely  to  be  the  most  efficient  of  sedative 
medicinal  remedies,  and,  judiciously  employed,  is  appar- 
ently without  subsequent  ill  effect.  The  bromides,  which 
are  administered  to  this  end  and  for  their  supposed  action 
in  diminishing  cerebral  congestion,  seem  to  be  void  of 
effect  even  when  carried  to  their  physiological  limit. 

The  nutrition  of  the  patient  in  every  serious  case,  what- 
ever its  nature,  whether  of  accident  or  disease,  requires 
careful  attention.  In  severe  brain  lesions  which  are  not 
immediately  fatal  the  restorative  processes,  if  they  occur  at 
all,  are  usually  slow,  and  the  issue  to  some  extent  may  de- 
pend upon  the  support  which  is  given  to  the  natural  powers 
of  endurance.  Alimentation  is  not  often  attended  with 
much  difficulty  in  the  earlier  stages  of  treatment,  or  while 
recovery  may  still  seem  hopeful  or  possible.  It  is  of  essen- 
tial importance  that  it  should  be  systematic  and  not  too  long 
deferred.  The  injunction  to  be  mindful  of  the  action  of 
the  bowels  and  of  the  evacuation  of  the  bladder,  which  is 
so  generally  coupled  with  that  of  careful  nutrition,  may 
15 


226  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

have  special  significance  in  relation  to  these  injuries  of  the 
brain.  In  a  considerable  proportion  of  cases,  the  lack  of 
urinary  and  fascal  control  may  render  it  superfluous;  but 
when  unconsciousness  is  profound  retention  of  urine  oc- 
casionally occurs,  and  in  all  pathic  cerebral  conditions  the 
importance  of  the  revulsive  effect  of  free  intestinal  action 
is  well  understood.  These  several  admonitions  to  caution, 
though  trite,  are  not  to  be  regarded  as  purely  perfunctory ; 
their  observance  is  of  absolute  importance,  and  their  neg- 
lect invites  disaster. 

There  are  certain  other  measures  of  treatment,  some- 
times adopted,  which  are  of  at  least  doubtful  expediency. 
There  may  exist  conditions  which  seem  to  indicate  deple- 
tion, and  the  application  of  a  leech  behind  the  ear  has 
been  followed  by  mitigation  of  urgent  symptoms;  but  it 
is  doubtful  if  the  gain  is  ever  permanent,  and,  failing  this, 
it  is  certain  that  the  collapse  of  the  patient  will  be  acceler- 
ated. The  alcohol  bath  will  cause  a  temporary  reduction 
of  several  degrees  in  high  temperatures,  and,  though  it 
sometimes  may  be  more  than  once  repeated,  the  tempera- 
ture each  time  regains  its  former  height.  This  is  appar- 
ently an  invariable  rule  when  the  danger  limit  of  heat  has 
been  exceeded ;  and,  if  so,  there  can  be  no  sufficient  reason 
for  this  resort,  since  moderate  elevations  will  not  require 
so  radical  a  measure.  The  iodide  of  potassium  is  still 
much  in  use  in  the  treatment  of  brain  injuries,  without 
regard  to  their  special  nature.  The  results  of  extended 
observation  fail  to  show  that  it  is  efficacious,  either  in  re- 
lieving circulatory  obstruction  or  in  the  absorption  of 
pial  effusions  or  of  cerebral  oedema. 


PRINCIPLES    OF   TREATMENT.  22/ 

SECONDARY    INFLAMMATIONS. 

I.  Arachnitis. 

The  treatment  of  traumatic  arachnitis  is  not  essen- 
tially different  from  that  of  the  idiopathic  form  of  the  dis- 
ease; it  will  demand  therefore  but  brief  consideration.  If 
serious  complication  of  hemorrhage  or  cerebral  lesion  exist, 
and  the  mixed  nature  of  the  lesions  is  recognizable,  very 
little  can  be  added  to  the  means  which  have  been  adopted 
to  meet  the  earlier  indications.  Cold  to  the  head,  if  not 
previously  applied,  is  the  one  depressant  which  may  be  tol- 
erated; blistering  is  not  only  useless,  but  harmful,  as  it 
increases  existing  general  irritation.  If  the  exudation  is 
distinctly  purulent,  or  the  result  of  pyogenic  infection, 
whether  or  not  there  may  be  complicating  injuries  of  the 
brain,  it  is  recognized  as  distinctly  fatal,  unless  there  may 
be  hope  in  operative  interference  by  which  effective  drain- 
age can  be  established.  That  resort  has  already  been  given 
consideration.  The  cases  in  which  recovery  seems  pos- 
sible are  those  in  which  arachnoid  inflammation  is  the 
direct  result  of  contusion,  without  serous  intracranial  com- 
plication and  without  subsequent  infection,  and  in  which 
the  exudation  is  mainly  of  a  serous  character.  It  is  not 
always  possible  during  life  to  determine  whether  the  in- 
flammatory product  is  either  in  part  or  wholly  purulent,  or 
whether  it  has  resulted  from  infection ;  but  in  view  of 
treatment  it  should  be  assumed,  pendente  lite,  to  be  serous 
or  sero-fibrinous.  The  treatment  of  idiopathic  arachnitis 
suggested  by  the  late  Dr.  Alonzo  Clark,  is  not  less  appli- 
cable to  the  traumatic  form  of  the  disease;  it  is  rational,  it 
has  been  at  least  quite  as  successful  as  any  other,  and  still 
retains  favor.     It  consists  essentially  in  the  use  of  counter- 


228  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

irritation  to  resolve  inflammation  and  of  diuretics  to  effect 
the  removal  of  its  serous  product  by  absorption.  The 
agencies  he  employed  were  blisters  and  the  iodide  of  po- 
tassium. If  the  symptoms  are  acute,  the  blistering  may 
be  preceded  by  the  application  of  ice  or  ice  water  to  the 
head;  or,  if  the  condition  of  the  patient  is  asthenic,  both 
blisters  and  the  cold  appliances  may  be  discarded.  Local 
depletion  may  be  indicated  in  individual  instances,  but  with 
great  infrequenc3^  The  strength  of  the  patient  must  be 
carefully  maintained  and  the  use  of  stimulants  may  be 
required  from  the  beginning. 

2.  Abscess. 

The  superficial  abscess,  which  is  nearly  ahvays  of  epi- 
dural origin,  may  come  to  involve  the  cerebral  surface. 
It  is  no  longer  of  common  occurrence,  and,  if  it  exists  at 
all,  is  an  incident  of  neglected  cranial  fracture.  Its  treat- 
ment has  been  already  intimated  in  a  former  reference  to 
its  symptomatology.  In  the  examination  of  such  a  case, 
which  will  be  suggested  by  the  general  indications  of 
septic  infection,  or  of  localized  cerebral  disturbance,  the 
cranial  fracture  will  be  necessarily  exposed  and  the  cranial 
cavity  opened.  If  the  pyogenic  process  has  extended  from 
without  inward,  the  abscess  will  be  at  once  disclosed.  In 
the  possible  contingency  that  the  pus  formation  is  limited 
to  the  arachnoid  cavity  and  subarachnoid  space,  the  ap- 
pearance of  the  dural  surface  will  unquestionably  indicate 
the  necessity  for  its  incision.  The  foundation  of  treatment 
and  its  operative  measures  are  thus  included  in  the  methods 
of  exact  diagnosis.  If  the  pus  is  thoroughly  removed,  the 
w^ound  disinfected,  drainage  provided,  and  absolute  aseptic 
conditions  are  maintained,  it  only  remains  to  give  such  at- 


PRINCIPLES    OF   TREATMENT.  229 

tention  to  the  nutrition,  stimulation,  and  general  constitu- 
tional management  as  may  be  required  for  primary  lesions. 
It  is  scarcely  conceivable  that,  with  the  exercise  of  care  in 
the  earlier  treatment  of  the  fracture  and  external  wound, 
such  a  complication  should  result. 

The  formation  of  a  superficial  intracranial  abscess, 
without  cranial  fracture  or  external  wound,  once  frequently 
encountered,  has  almost  if  not  entirely  disappeared  from 
modern  hospital  practice.  The  bone  was  contused,  became 
inflamed,  and  was  subsequently  necrosed,  with  concurrent 
periostitis  and  pachymeningitis.  Pus  formed  between  the 
bone  and  pericranium,  and  between  the  bone  and  the  dura 
mater,  and  might  later  extend  to,  or  involve  the  cerebral 
surface.  Its  external  manifestation  was  a  swelling  known 
as  Pott's  puffy  tumor  of  the  scalp.  The  history  of  local  in- 
jury, the  existence  of  tumor,  and  the  coincidence  of  symp- 
toms of  septic  infection  and  cerebral  disturbance,  confirmed 
the  diagnosis.  The  local  and  the  general  treatment  were 
thereafter  the  same  as  when  the  original  injury  had  in- 
volved a  compound  fracture,  rather  than  a  simple  contusion, 
of  the  bone. 

The  hernia  cerebri,  which  is  allied  to  superficial  cerebral 
abscess,  is  another  accident  of  cranial  injury  with  dural 
implication  which  is  no  longer  frequent.  It  is  a  tumor  of 
variable  size,  in  some  part  composed  of  brain  elements, 
but  in  larger  proportion  of  inflammatory  products,  which 
protrudes  through  a  perforation  of  the  cranial  wall.  It 
presupposes  a  cranial  opening,  whether  from  accident  or 
operation,  a  wound  of  the  dura  mater  and  an  inflammation 
of  the  cerebral  surface  with  or  without  a  pyogenic  process 
which  softens  its  structure  and  permits  its  extrusion  by  the 
force  derived   from  the  pulsation  of  the  cerebral  vessels. 


230  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

It  is  of  impossible  occurrence  unless  the  road  has  been 
opened  and  the  brain  substance  has  been  at  the  same  time 
sufficiently  altered  by  inflammatory  changes.  Aseptic 
methods  have  so  prevented  or  limited  such  degenerations  of 
cerebral  tissue  that  this  complication  has  not  only  ceased 
to  be  a  menace,  but  is  no  longer  a  source  of  great  danger 
in  the  exceptional  instances  in  which  it  occurs.  If,  with 
considerable  loss  of  cranial  and  dural  support,  correspond- 
ing injury  of  the  cerebral  surface  has  been  inflicted,  some 
protrusion  of  the  brain  substance  may  be  inevitable ;  but  if 
the  wound  has  been  aseptically  treated  the  tumor  will  con- 
tain but  a  small  proportion  of  inflammatory  products,  and 
will  usually  be  amenable  to  a  continuance  of  aseptic  treat- 
ment, in  conjunction  with  moderate  pressure  equably  sus- 
tained. It  is  still  possible  that  the  tumor,  from  neglect  of 
early  treatment,  will  eventually  require  excision,  but  this 
procedure  will  no  longer  entail  the  danger  with  which  it 
was  formerly  attended.  The  septic  conditions  which  al- 
ready exist  will  by  present  methods  be  diminished  rather 
than  increased  by  operation. 

Deep  Abscess. 

The  traumatic  central  abscess  of  the  brain,  unlike  the 
superficial  inflammations  just  described,  is  often  deter- 
mined by  unknown  circumstances  in  which  neglect  has  had 
no  obvious  part.  The  fact  of  its  only  exceptional  occur- 
rence, even  before  the  necessity  of  surgical  cleanliness  was 
recognized,  the  possibility  that  external  wound  may  be 
wantinof,  and  the  usual  tenor  of  such  histories  as  can  be 
obtained,  do  not  seem  to  indicate  either  its  uniform  or  its 
habitual  origin  in  superficial  injury.  There  is  therefore 
less  stress  to  be  laid  upon  the  efficacy  of  a  preventive  treat- 


PRINCIPLES    OF   TREATMENT.  23 1 

ment,  though  from  this,  as  from  every  point  ot  view,  the 
observance  of  rigid  aseptic  precautions  is  to  be  enjoined  in 
the  management  of  all  injuries  of  the  head.  There  can  be 
no  special  treatment  in  the  formative  stage  of  the  abscess ; 
as  there  are  no  recognizable  s^^mptoms,  there  can  be  no 
direct  indications.  Treatment  can  begin  only  when  the 
abscess  has  attained  such  size  that  it  can  be  recognized,  or 
at  least  reasonably  suspected ;  and  then  if  deemed  justi- 
fiable must  be  purely  operative.  There  is  no  diversity  of 
opinion,  and  hence  can  be  no  discussion  as  to  the  almost 
certain  fatality  of  even  encapsulated  purulent  accumula- 
tions in  the  brain  substance  when  undisturbed ;  nor  as  to 
the  possibility  of  their  successful  evacuation  by  operation 
under  favorable,  and  sometimes  under  unfavorable,  cir- 
cumstances. If  the  progress  of  a  case  has  led  to  a  well- 
founded  conviction  that  abscess  exists,  and  the  general 
condition  of  the  patient  promises  safety  in  case  of  opera- 
tive failure,  exploration  should  be  made ;  or  if  action  has 
been  delayed  till  diagnosis  is  practically  certain,  or  till  a 
sudden  irruption  of  symptoms  unexpectedly  discloses  the 
nature  of  the  lesion,  and  it  is  accessible,  operation  should 
be  essayed,  though  only  a  forlorn  hope  of  a  successful  issue 
remains.  The  situation  of  the  cyst  will  be  determined,  so 
far  as  its  determination  is  practicable,  by  the  general  con- 
sideration of  symptoms  upon  which  the  fact  of  its  existence 
was  predicated,  aided  incidentally  perhaps  by  a  knowledge 
of  the  external  seat  of  original  injury.  The  spontaneous 
discharge  of  pus  through  a  cranial  wound,  if  such  was 
originally  inflicted,  or  through  natural  passages,  is  too  im- 
probable to  be  made  the  basis  of  speculation  or  of  reliance. 
It  is  possible,  especially  in  case  of  gunshot  wounds,  but 
even  then  indicates  operative  interference.     These  formu- 


232  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

lated  statements  are  believed  to  be  in  accordance  with  the 
views  of  surgeons  generally  and  of  writers  upon  the  sub- 
ject. 

The  choice  of  site  for  operation,  the  details  of  proce- 
dure, the  disinfection  of  the  abscess  cavity,  and  the  question 
of  drainage  have  been  thoroughly  discussed  by  ]\Iacewen 
and  others. 

The  appended  series  of  fatal  and  recovering  cases  in- 
cludes but  five,  or  one  per  cent,  of  the  whole  number, 
which  involved  a  pyogenic  process  of  the  parenchyma. 
One  of  these  was  a  diffuse  inflammation  resulting  from 
the  use  of  an  infected  drainage  tube ;  three  of  the  four 
abscesses  followed  early  neglect  and  a  late  admission  to 
the  hospital,  and  were  probably  preventible.  There  were 
two  recoveries,  both  after  operation ;  one  in  case  of  a  cor- 
tical, and  the  other  of  a  central  suppuration.  In  one  of 
the  two  fatalities  a  small  abscess  was  evacuated,  and  in  the 
other  an  operation  was  not  deemed  practicable  in  the  con- 
dition of  the  patient. 

These  cases  are  included  in  the  series  appended. 


PART    II. 

PISTOL-SHOT    WOUNDS    OF   THE    HEAD. 


Chapter  VII. 


MEDICO-LEGAL   RELATIONS. 

The  increasing  frequency  of  pistol  -  shot  wounds, 
whether  accidental,  suicidal,  or  homicidal,  has  added  to 
their  recognized  importance  as  a  distinctive  class  of  general 
injuries.  The  pistol  is  essentially  the  weapon  of  modern 
life ;  hionest  men  carry  it  for  defence,  other  men  use  it  for 
defence  or  offence  as  occasion  serves;  it  is  accessible  as 
well  as  congenial  to  the  temperament  of  the  time,  and  so 
suits  the  suicidal  purpose ;  the  results  of  ordinary  careless- 
ness render  it  additionally  the  fruitful  source  of  accident. 
The  countless  wounds  which  it  occasions  are  inflicted  upon 
the  head  with  disproportionate  frequency  as  compared  with 
other  regions  of  the  body,  and  have  then  peculiarities  which 
demand  special  consideration  in  a  comprehensive  view  of 
intracranial  lesions. 

Pistol-shot  wounds  of  the  head  are  of  importance  in  two 
distinct  relations :  as  they  concern  medico-legal  inquiries, 
and  in  their  purely  surgical  aspect  as  a  subdivision  of  the 
class  of  encephalic  injuries. 

Gunshot  wounds  have  been  carefully  studied  at  differ- 
ent epochs,  and  the  effects  of  different  arms  and  projectiles 


234  INJURIES    OF    THE    BRAIN   AND    MEMBRANES. 

at  long  range  have  been  determined  with  some  accuracy 
both  by  observation  and  by  direct  experimentation.  The 
close  of  each  great  conflict  of  arms  in  modern  times  has 
been  followed  by  such  additions  to  the  literature  of  the 
subject  as  have  been  necessitated  by  the  attainment  of  suc- 
cessive increments  of  destructive  power.  The  observations 
of  John  Hunter  were  made  from  1760  through  various 
Continental  wars,  and  were  terminated  only  with  his  death 
toward  the  end  of  the  century.  From  that  time  till  the 
conclusion  of  the  Franco-Prussian  war,  a  period  crowded 
with  historic  military  operations  of  great  extent,  not  only 
in  Europe  but  in  the  East  and  in  this  country,  progressive 
improvements  in  arms  and  projectiles  have  been  constantly 
paralleled  by  equal  advances  in  the  knowledge  of  the  in- 
juries which  they  inflict,  and  facts  established  by  experi- 
ence in  the  field  have  been  supplemented  by  the  later  ex- 
perimental observations  of  Bruns,  Chaumel,  and  Nimier, 
and  of  many  others,  and  very  recently  by  those  of  La  Garde 
under  the  direction  of  the  Ordnance  and  vSurgeon-General's 
departments  of  the  United  States  Army.  The  results  thus 
obtained  may  be  held  to  be  limited  to  wounds  inflicted  at 
long  range.  The  pistol  plays  so  small  a  part  in  actual  war- 
fare that  it  would  be  as  useless  as  it  is  impossible  to  dis- 
criminate the  occasional  wounds  it  has  produced  from  the 
incomparably  greater  number  due  to  other  small  arms  in 
habitual  military  use.  The  experiments  on  the  cadaver, 
furthermore,  which  have  been  conducted  by  military  sur- 
geons have  never  included  studies  of  the  special  character- 
istics of  pistol-shot  wound.  Their  history  must  be  sought 
in  civil  life,  to  which  their  ravages  have  been  largely  con- 
fined and  in  which  their  interest  mainly  centres. 


medico- legal  relations.  235 

The  Medico-Legal  Relations  of  Pistol-Shot 
Wounds  of  the  Head. 

The  medico-legal  significance  of  pistol-shot  wounds  of 
the  head  is  in  great  part  dependent  upon  the  character  of 
the  injuries  suffered  by  the  soft  parts  and  by  the  cranium. 
The  question  of  homicide  or  suicide  may  depend  exclu- 
sively for  its  solution  upon  the  possibility  of  thus  determin- 
ing the  distance  at  which  a  fatal  shot  was  fired,  its  direc- 
tion, or  its  calibre.  The  intracranial  wound  may  afford 
corroboration  of  the  inferences  derived  from  an  examina- 
tion of  the  external  appearances,  but  in  this  regard  its 
value  is  relatively  slight.  The  surgical  importance  of  head 
injuries  of  this  class,  on  the  contrary,  will  rest  in  great 
part  upon  the  damage  sustained  by  the  intracranial  con- 
tents. 

Generalizations  founded  upon  clinical  observation  have 
a  basis  too  narrow  to  make  them  of  use  in  the  interpreta- 
tion of  facts  pertinent  to  medico-legal  investigation.  The 
number  of  instances  for  comparison,  made  necessary  by 
the  diversity  of  attendant  circumstances,  is  too  great  to  be 
compassed  within  the  limit  of  individual  experience,  even 
when  favored  by  exceptional  opportunity.  In  other 
varieties  of  gunshot  injury  examples  may  be  at  times  in- 
definitely aggregated,  as  will  happen  in  the  course  of  mili- 
tary operations.  There  is  the  further  difficulty  encoun- 
tered that  the  conditions  under  which  the  wound  has  been 
inflicted  can  rarely  be  determined  with  precision.  The 
calibre  of  the  ball,  the  distance  from  which  it  has  been  pro- 
jected, its  direction,  and  even  the  nature  of  the  explosive, 
may  be  positively  known,  if  at  all,  only  from  the  state- 
ment of  the  homicidal  or  suicidal  victim,  who  is  not  often 


236  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

in  a  mental  or  physical  state  to  afford  definite  information. 
In  gunshot  wounds  inflicted  upon  the  field  of  battle,  dis- 
tances are  estimated  at  hundreds  of  yards,  and  with  other 
essential  conditions  are  predetermined  and  definitely  for- 
mulated. In  pistol-shot  wounds,  distances  are  usually  cal- 
culated upon  a  scale  of  feet  or  inches,  and  distinctions 
must  necessarily  be  more  minutely  drawn.  There  are  no 
established  data  from  which  deductions  can  be  made,  and 
perhaps  no  other  witness  with  knowledge  of  explanatory 
facts  than  the  suicide  or  murderer,  whose  lips,  as  already 
said,  are  sealed  by  mental  or  physical  disability,  or  by  the 
instinct  of  self-preservation.  Another  source  of  inexacti- 
tude or  failure  in  generalization  exists  in  the  alteration  or 
destruction  of  evidences  impressed  upon  the  external  sur- 
face of  the  body.  The  wound  may  have  been  enlarged 
or  distorted,  unburned  grains  of  powder  may  have  been 
removed,  or  smoke  stains  may  have  been  washed  away. 

As  a  result  of  these  several  causes  of  uncertainty,  the 
limitation  of  individual  experience,  the  lack  of  positive 
knowledge  of  all  the  circumstances  under  which  the  injury 
has  been  received,  and  the  changes  to  which  the  external 
wound  and  the  adjacent  cutaneous  surface  have  been  pos- 
sibly subjected,  there  are  but  few  opportunities  afforded 
for  satisfactory  clinical  observation  of  the  results  of  pistol 
shots  under  exactly  specified  conditions  of  weapon,  missile, 
distance,  and  direction.  It  would  be  difficult  to  find  even 
an  exceptional  instance  in  which  one  or  more  elements 
necessary  to  comparison  were  not  wanting. 

In  order  to  determine  the  effects  produced  by  balls  of 
different  calibres,  fired  at  different  distances  and  under 
varied  conditions,  it  is  necessary  to  resort  to  experimen- 
tation upon  the  cadaver.     Results  obtained  in  this  manner, 


MEDICO-LEGAL    RELATIONS.  237 

■when  confined  to  lesions  and  disfigurements  of  the  scalp 
and  cranium,  if  not  identical  with  those  observed  in  the 
case  of  similar  injuries  inflicted  upon  the  living  subject, 
are  sufficiently  approximate  to  have  weight  in  the  forma- 
tion of  medico-legal  conclusions.  The  allowances  which 
are  to  be  made  for  the  physical  changes  which  have  oc- 
curred in  those  parts  in  the  quite  recent  post-mortem  con- 
dition are  scarcely  greater  than  those  required  for  the  vari- 
ations in  individual  clinical  cases.  Such  experiments  have 
been  undertaken  from  time  to  time,  but  they  have  been 
heretofore  desultory  in  character,  limited  in  scope,  impo- 
tent in  conclusion,  and  infrequently  or  inexactly  recorded. 

A  very  great  number  of  observations  systematically 
made  is  essential  to  the  formulation  of  rules  which  govern 
the  infliction  and  reception  of  this  type  of  gunshot  wound. 
The  calibre  of  the  ball,  its  angle  of  incidence,  and  the  dis- 
tance which  it  traverses  must  not  only  be  considered,  but, 
additionally,  the  length  of  the  Aveapon,  the  character  of  the 
explosive,  the  density  and  thickness  of  the  individual 
cranium,  and  the  special  cranial  region  which  is  involved. 
It  is  of  course  impossible  experimentally  to  fix  the  exact 
value  of  each  one  of  these  elements  through  all  its  con- 
ceivable permutations.  If  experiments  be  confined  to  the 
effects  of  balls  of  the  four  sizes  in  most  frequent  use,  fired 
from  a  single  variety  of  pistol,  and  at  distances  varying 
from  contact  to  the  limit  at  which  penetration  of  bone  is 
possible  for  each  calibre,  the  number  demanded  will  even 
then  be  very  large.  If  each  observation  be  repeated  suffi- 
ciently often  to  discriminate  occasional  or  uncertain  effects 
from  those  which  are  invariable,  their  total  number  will  be 
enormously  increased. 

In  a  series  of  experiments  made  upon  the  cadaver  dur- 


238  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

ing  the  past  three  years,  the  author  has  proceeded  in  the 
manner  which  seems  essential  to  the  formation  of  definite 
conclusions.  The  calibres  selected  were  0.22,  0.32,  0.38, 
and  0.44.  The  cartridges,  like  the  pistols  primarily  used, 
were  of  a  single  manufacture,  and  the  distances  were  the 
same  for  each  calibre,  varying  from  absolute  contact  of  the 
weapon's  muzzle  with  the  skin  to  the  limit  of  practicable 
observation,  which  was  fixed  at  one  hundred  feet.  For 
further  comparison  a  limited  number  of  additional  obser- 
vations was  made  with  pistols  and  cartridges  from  other 
makers,  and  also  with  the  smokeless  in  place  of  the  black 
powder.  The  trials  were  made  upon  entire  subjects  re- 
cently dead,  in  which  cadaveric  rigidity  did  not  exist  and 
in  which  decomposition  was  not  appreciably  advanced.  In 
such  heads  the  physical  properties  of  the  cranium  may  be 
considered  as  unaltered,  and  changes  in  the  superficial 
soft  parts  as  insufficient  materially  to  afi^ect  results.  The 
influence  of  regional  variations,  and  of  differences  in  the 
thickness  or  density  of  individual  crania,  upon  the  amount 
and  character  of  injury  wrought  by  the  missile  was  inci- 
dentally apparent  in  the  course  of  observations  of  a  more 
general  character. 

The  effects  of  pistol  shots  upon  the  head  which  were 
especially  studied  were  lesions  of  the  tegumentary  cov- 
erings and  of  the  cranium ;  intracranial  injuries  were 
regarded  as  of  less  certain  value  on  account  of  possible 
modifications  from  changes  incident  to  the  post-mortem 
condition  in  so  soft  a  tissue  as  the  brain  substance. 

The  specific  effects  noted  and  subjected  to  comparison 
were,  for  the  external  soft  parts,  the  characteristics  of  the 
external  wound  of  entrance,  the  burning  of  the  skin  or 
hair,  the  staining  of  the  skin  by  smoke,  and  the  deposit  of 


MEDICO-LEGAL   RELATIONS.  239 

unburned  grains  of  powder  upon  the  surface  or  in  the  sub- 
stance of  the  skin  or  subjacent  wounded  tissues ;  and  for 
the  cranium,  the  peculiarities  of  the  osseous  wounds  of 
entrance  and  of  exit,  and  the  resulting  fractures  of  the 
vault  or  base.  To  these  were  added  an  examination  of 
the  brain  track  for  the  detection  of  powder  traces  or  of 
bony  fragments. 

Extracranial  Lesions. 

0.38  calibre. 
Length  of  barrel,  3%". 
Diameter  of  ball,  0.430". 
Weight  of  lead,  146-150  grs. 
Weight  of  powder,  15-19  grs. 

Number  of  observations  made  upon  the  head,  io8. 
Number  of  observations  made  upon  the  body,  132. 

The  effects  of  balls  of  this  calibre  were  given  earliest 
consideration  and  in  some  sort  made  standards  of  com- 
parison for  those  occasioned  by  others  of  larger  or  smaller 
size,  since  they  are  not  only  more  commonly  encountered 
but  also  present  greater  uniformity  of  character. 

The  wound  of  entrance  is  at  all  ranges  smaller  than 
the  ball,  circular  except  for  an  occasional  minute  tear,  and 
from  -^'^  to  3^"  in  diameter.  The  margin  is  sometimes 
slightly  inverted,  or  may  be  finely  serrated,  and  when  the 
range  is  greater  than  3"  is  often  stained  with  lead. 

Exceptions. — {a)  If  the  ball  strikes  upon  a  cranial  curve, 
the  cutaneous  wound  may  be  lacerated  and  its  size  in- 
creased to  a  moderate  extent.  {b)  At  contact  of  the 
weapon,  and  occasionally  even  when  the  range  is  Y^" ,  the 


240  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

wound  is  much  larger  than  the  ball,  and  the  subcutaneous 
tissues  are  disclosed,  torn,  and  burned,  or  blackened  by 
powder  and  smoke.  The  wound  is  then  usually  linear, 
from  i"  to  2"  in  length,  and  often  made  secondarily  trian- 
gular by  the  rupture  of  one  of  the  cutaneous  edges.  It 
may  possibly  be  quadrilateral,  or  even  circular,  but  is 
always  comparatively  large,  though  in  that  event  smaller 
than  the  ball. 

Disintegrated  brain  matter  may  be  forced  through  the 
wound  of  entrance  at  all  ranges,  and  this  will  occur  in  the 
larger  proportion  of  cases.  It  may  simply  bulge  from  the 
wound,  lie  upon  the  adjacent  surface,  be  entangled  in  the 
hair,  or  be  ejected  to  a  considerable  distance,  as  far  even 
as  fifteen  or  twenty  feet.  The  amount  varies  from  a  bit  not 
larger  than  a  robin  shot  to  as  much  as  one  or  two  drachms. 
As  the  extrusion  of  brain  matter  occurs  at  all  ranges,  and 
its  quantity  and  force  of  ejection  depend  in  part  upon  other 
circumstances,  it  has  no  value  in  determining  the  distance 
through  which  the  ball  has  been  projected. 

Smoke  stain  upon  the  skin  does  not  occur  at  firm 
contact,  but  when  contact  is  imperfect,  and  at  a  range  less 
than  6"  it  is  nearly  constant.  The  exceptions  are  in  certain 
cases  in  which  the  wound  is  made  in  a  portion  of  the  head 
covered  with  thick  hair,  and  in  the  rarer  cases  in  which  at 
a  range  of  ^"  the  wound  is  lacerated  and  the  subcutaneous 
tissues  are  widely  disclosed.  At  a  range  from  6"  to  one 
foot  it  is  again  nearly  constant ;  from  one  foot  to  two  feet  it 
is  of  more  uncertain  occurrence.  At  a  range  of  more  than 
two  feet  it  is  always  absent  as  a  distinct  area,  though  it  may 
be  perhaps  detected  with  a  damp  cloth.  The  smoke-stained 
area  is  usually  circular  and  dark,  with  an  extension  of 
lighter  hue,  which  may  be  either  symmetrical,  irregular,  or 


i6 


242  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

prolonged  upon  one  aspect  of  the  wound,  and  possibly  with 
smudges  upon  neighboring  prominences  or  depressions,  as 
upon  the  ear  or  nose  or  in  the  orbital  fossae.  These  areas 
are,  approximately:  at  ranges  of  less  than  i",  from  i^/^"  to 
2%"  diam. ;  at  ranges  of  i"  to  3",  from  3"  to  5"  diam. ;  at 
ranges  of  6",  from  2^"  to  4"  diam.;  and  at  ranges  from 
one  foot  to  two  feet  either  very  small,  not  more  than  i"  in 
diam.,  or,  as  usually  happens,  very  largely  and  faintly 
diffused  over  an  irregular  space  of  from  5"  to  6".  At  a 
range  of  ^"  to  3"  there  is  ordinarily  a  deeply  blackened 
circular  area  from  %"  to  ^ "  in  diameter,  surrounding  the 
wound,  which  is  the  combined  result  of  smoke,  burn,  and 
infiltration  of  the  skin  with  finely  divided  grains  of  powder. 
With  imperfect  contact  of  the  weapon  a  double  smoke  ring 
may  be  formed  with  a  clear  interval  between  the  two,  hav- 
ing an  entire  diameter  of  two  inches.  The  density  of  the 
smoke  deposit,  the  probability  of  its  occurrence  at  the 
uncertain  ranges,  and  its  extension  to  more  distant  surfaces 
will  be  influenced  by  atmospheric  conditions.  Each  will 
be  notably  as  well  as  naturally  favored  by  an  excess  of 
dampness,  but  the  accuracy  of  the  conclusions  stated  will 
not  be  further  affected. 

Burning  or  scorching  of  the  skin  occurs  only  at  a 
range  of  less  than  one  foot.  At  contact  or  at  a  range  of  %" 
it  is  confined  to  the  edge  of  the  cutaneous  wound,  as  it  is 
when  with  a  range  of  yi"  or  less  the  soft  parts  are  lacer- 
ated. At  a  range  from  yi"  to  6"  inclusive  there  is  usually 
a  circular  blackened  area  yi"  to  3^"  in  diameter,  due  in 
part  to  burn,  as  previously  described.  In  a  single  instance 
it  exceeded  this  limit ;  it  is  invariable  if  not  prevented  by 
the  thickness  of  the  hair  at  the  point  of  injury.  At  a  range 
from    i"    to   6"    inclusive    the    skin    may   be    additionally 


244  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

scorched,  either  over  a  circular  area  of  i"  to  i^"  alto- 
gether, or  upon  one  aspect  of  the  wound.  At  any  of  these 
ranges,  the  hair,  if  interposed,  will  be  burned  or  singed 
over  an  area  from  i"  to  2jj"  in  extent,  and  may  or  may 
not  prevent  burning  or  other  characteristic  lesions  of  the 
skin.  At  a  range  of  7"  to  10"  the  blackened  area  is  not 
formed,  and  burning  is  again  limited  to  the  edge  of  the 
cutaneous  wound,  or  to  a  slight  singeing  of  the  hair,  or  it 
may  be  entirely  absent.  Burning  is  not  constant  at  any 
range. 

Unburned  grains  of  powder  may  lie  upon  the  surface 
of  the  skin  or  be  more  or  less  completely  embedded  in  its 
substance.  At  contact  or  at  a  range  of  y^"  no  such  indica- 
tion exists,  but  in  its  place  there  is  a  powder  infiltration  of 
the  exposed  subcutaneous  tissues,  and  a  distribution  of  un- 
burned grains  upon  the  detached  surface  of  the  temporal 
fascia  or  of  the  fronto-occipital  aponeurosis.  The  skin  is 
ingrained  with  powder  at  ranges  from  ^"  to  four  feet  in- 
clusive, but  at  three  feet  the  ingraining  ceases  to  be  invari- 
able. At  ^  "  or  I "  it  is  confined  to  the  blackened  area  of  yi " 
to  3^"  diam.  At  3"  it  is  extended  to  an  area  of  i^"  to  2^"; 
at  6",  to  an  area  of  2^"  to  4",  which  is  not  much  increased 
up  to  a  range  of  one  foot,  though  the  average  becomes  con- 
stantly greater.  At  ranges  of  one  foot  and  two  feet  it  in- 
cludes an  area  of  4"  to  6",  and  in  the  case  of  wound^ involving 
the  anterior  temporal  region  covers  the  whole  side  of  the 
face,  neck,  and  ear.  At  three  and  one  half  and  four  feet, 
in  half  the  observations  made,  no  grains,  and  in  the  others 
not  more  than  two  or  three,  were  embedded.  These  areas 
represent  extreme  measurements,  but  the  greater  part  of 
the  implantations  were  made  within  somewhat  narrower 
limits,  and  as  the  range  increased  they  were  more  widely 


^m 


246  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

separated  from  each  other.  The  number  is  difficult  to  es- 
timate; at  a  range  from  3"  to  two  feet  it  is  probably  from 
200  to  400  or  even  more ;  at  three  feet  they  may  be  counted, 
and  the  total  number  will  probably  not  exceed  25  to  50,  and 
may  be  not  more  than  3  or  4,  and  at  four  feet  there  will 
be  2  or  3  or  none  at  all.  At  six  feet  they  no  longer 
exist. 

Unburned  grains  which  are  free  upon  the  cutaneous 
surface  are  not  distinguishable  when  the  range  is  less  than 
6",  though  they  may  be  seen  upon  the  underlying  cloth. 
There  are  more  grains  free  at  a  range  of  lo",  and  still  more 
at  one  foot,  but  those  which  are  fixed  in  the  skin  .still 
preponderate.  At  a  range  of  two  feet  the  proportion  is 
variable ;  at  three  feet  the  greater  part  are  free ;  and  at 
four  feet  only  an  occasional  grain  is  embedded ;  at  ranges 
of  six  feet  and  upward  whatever  grains  escape  combustion 
are  free  upon  the  surface  of  the  adjacent  parts  or  else- 
where. The  grains  are  many  at  six  feet,  but  at  eight  or 
nine  feet  and  up  to  a  range  of  not  much  short  of  thirty  feet 
there  are  rarely  more  than  six  or  eight,  oftener  one  or  two, 
and  in  many  instances  none  at  all.  At  and  beyond  a 
range  of  thirty  feet  not  even  a  single  grain  has  been  found 
in  any  of  the  observations  made.  Within  the  limit  in 
which  fixed  and  free  grains  exist  together  their  area  is 
commensurate.  At  a  range  of  from  one  foot  to  six  feet  the 
whole  side  of  the  face  and  neck  and  the  ear  is  likely  to  be 
included.  At  the  longer  ranges  in  which  there  is  but  a 
grain  or  two,  or  at  most  but  five  or  six,  they  are  found  or- 
dinarily at  a  distance  from  the  wound,  even  as  far  as  the 
hip,  though  if  it  be  but  a  single  grain  it  may  have  made  its 
lodgement  almost  upon  the  margin  of  entrance.  In  general 
the  number  of  free  grains  increases  relatively  as  that  of  the 


s  ^ 


248  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

fixed  grains  diminishes,  and  as  the  range  is  increased  both 
are  more  sparsely  scattered.  If  a  white  cloth  be  placed 
under  the  head  and  shoulders  of  the  subject,  unburned 
grains  will  often  be  detected  when  they  fail  to  appear  upon 
the  surface  of  the  head  or  face,  but  none  when  the  range 
exceeds  the  already  determined  distance  of  thirty  feet. 

Lesions  of  the  subcutaneous  tissues  occur  from  a  dis- 
charge of  the  weapon  at  contact  to  a  range  of  one  foot  in- 
clusive. At  contact  these  tissues  are  lacerated,  burned, 
smoked,  and  infiltrated  with  powder,  and  the  blackened 
surface  is  disclosed  through  the  cutaneous  wound.  In  ex- 
ceptional cases  these  conditions  may  be  produced  in  a  wound 
inflicted  at  a  range  of  y^" .  At  a  range  of  %"  to  3"  the 
superficial  tissues  are  usually  separated  from  the  temporal 
fascia  or  occipito-frontal  aponeurosis,  which  is  powder 
stained  over  an  area  of  %"  to  2".  At  a  range  of  6"  or 
more,  if  any  stain  exists  it  is  not  likely  to  extend  beyond 
the  track  of  the  ball,  though  grains  of  powder  may  be  ex- 
ceptionally discovered  at  one  foot.  At  a  distance  of  3"  or 
less  in  range  the  contiguous  surfaces  of  the  cranium  and 
dura  mater  may  be  powder  stained  over  an  area  of  yi "  to 
2",  or  the  margin  of  the  osseous  wound  upon  its  outer  sur- 
face may  be  similarly  stained  for  a  variable  distance.  The 
occurrence  of  fragments  or  particles  of  lead  in  the  tissues, 
especially  in  the  muscle,  or  of  a  lead  stain  of  the  bone  or 
pericranium,  is  frequent  when  the  range  is  3"  or  more,  and 
almost  invariable  at  the  longer  distances. 

Unburned  powder  is  carried  through  the  whole  length 
of  the  brain  track  when  the  ball  is  discharged  at  contact  or 
when  the  range  is  not  greater  than  }4".  At  a  range  of  i" 
it  may  not  be  detected  beyond  the  median  fissure ;  at  3" 
it  ceases  to  be  invariable,  and  the  quantity  is  much  dimin- 


Fig.  =.— 0.38  Cal.     Range,  i  ft.    Trace  of  Smoke,  Free  and  Embedded  Powder  Grains 


250  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

ished;  at  6"  it  apparently  no  longer  penetrates  the  cranial 
opening.  At  greater  distances  the  brain  substance  is  oc- 
casionally stained  with  lead. 

Fragments  of  bone  more  or  less  finely  comminuted 
may  be  driven  into  or  through  the  brain  at  whatever 
range  the  ball  has  been  projected.  Their  number  and 
size,  and  the  depth  to  which  they  are  carried,  will  de- 
pend rather  upon  the  physical  properties  of  particular 
crania  and  upon  the  point  or  angle  of  incidence,  than 
upon  the  distance  which  the  ball  has  traversed.  They 
have  therefore  no  significance  in  the  determination  of 
ranges. 

These  results  have  been  corroborated  in  certain  par- 
ticulars by  observations  made  upon  other  parts  of  the  body. 
The  characters  of  the  wound  of  entrance  or  of  the  subcu- 
taneous lesions  might  conceivably  differ,  by  reason  of 
different  relations  of  bone  and  superincumbent  tissues,  as 
the  wound  is  inflicted  upon  the  head  or  upon  the  trunk  or 
extremities;  but  the  results  of  imperfect  combustion  of 
powder  and  the  effects  of  flame,  the  area  of  smoke  stain, 
the  distribution  of  unburned  grains,  the  burning  of  the 
skin,  ought  to  be  approximately  the  same  in  the  two  classes 
of  cases.  In  one  hundred  and  thirty-two  corroborative 
observations  of  this  kind  comparison  has  been  restricted  to 
those  incidents. 

At  absolute  contact,  not  only  upon  the  thigh  and  thorax, 
but  over  the  skin  or  sternum  where  the  relation  of  skin  to 
subjacent  bone  is  more  exactly  comparable  to  that  which 
exists  in  the  head,  the  deposit  of  smoke  is  not  limited  to 
the  subcutaneous  tissues  but  also  occurs  upon  the  surface 
over  an  area  of  from  }^"  to  i".  At  a  range  of  i"  and  less 
the  cutaneous  smoke  area  is  larger  than  upon  the  head,  but 


\ 


-  '^•■f 


f;f^' 


Fig.  6.— 0.38  Cal.     Range,  2  ft.     Free  Powder  Grains,  only  Seven   Embedded. 


2  52  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

at  3",  6",  and  one  foot  it  is  very  nearly  the  same,  and  at 
all  these  ranges  it  is  constant.  From  one  foot  to  two  feet 
it  is  uncertain,  and  subject  to  similar  variations,  and  at  two 
feet  it  is  no  longer  visible  even  in  exceptional  cases.  Hence 
the  only  point  of  difference  noted  is  in  the  extent  of  the 
smoke  stain  at  a  range  of  i"  or  less. 

As  upon  the  head,  burning  or  scorching  of  the  skin  at 
contact  is  limited  to  the  cutaneous  edge.  At  ranges  of 
less  than  one  foot  it  has  about  the  same  extent  and  char- 
acters as  was  found  to  exist  at  corresponding  distances  in 
head  cases,  and  as  in  them  it  never  occurs  when  the  range 
reaches  or  exceeds  one  foot. 

The  correspondence  in  results  obtained  in  the  two 
classes  of  cases  is  extended  to  the  distribution  of  powder 
grains  which  escape  combustion.  At  contact  under  the 
exceptional  condition  which  permits  the  staining  of  the 
skin  with  smoke,  some  grains  may  be  embedded  in  its  area. 
The  narrow  blackened  margin,  due  to  burn,  smoke,  and 
infiltration  of  finely  divided  grains  of  powder,  which  at 
ranges  of  yi"  and  i"  or  more  was  found  to  environ  the 
wound  as  it  occurs  in  the  head,  is  reproduced  in  those  of 
the  body,  and  to  it  is  equally  confined  the  deposit  of  un- 
burned  grains.  At  ranges  extending  from  3"  to  four  feet  the 
areas  of  embedded  grain  do  not  materially  differ  from  those 
previously  established ;  and  at  greater  distances,  though  no 
longer  embedded,  they  may  as  before  be  detected  lying 
free  upon  the  cutaneous  surface,  or  upon  the  white  cloth 
which  underlies  the  body.  At  ranges  greater  than  four 
feet,  as  before,  the  number  of  free  grains  is  at  once 
greatly  diminished ;  their  presence  very  soon  becomes  un- 
certain, and  at  some  point  just  short  of  thirty  feet  they 
disappear  altogether. 


254  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

•   0.32  cal. 

Length  of  barrel,  3%". 
Diameter  of  ball,  0.319". 
Weight  of  ball,  88  grs. 
Weight  of  powder,  10  grs. 
Number  of  observations  made,  82. 

The  results  of  observation  do  not  differ  widely  from 
those  obtained  when  the  ball  is  of  0.38  cal. 

The  wound  of  entrance  is  still  found  to  be  smaller  than 
the  ball,  with  the  same  exceptions,  that  is,  at  contact,  or 
in  the  occasional  instances  in  which  it  is  lacerated  by  im- 
pact of  the  ball  upon  a  cranial  curve.  Its  diameter  will 
vary  between  the  same  limit  of  yY'  and  j^",  and  the  aver- 
age is  not  perceptibly  less.  At  contact,  however,  the 
wound,  which  is  still  usually  linear,  is  shorter,  not  often 
exceeding  i"  in  length,  and  is  more  likely  to  show  its 
original  circular  outline  with  the  tear  on  either  side  which 
has  made  it  linear.  It  is  less  likely  to  be  further  compli- 
cated by  a  secondary  tear  upon  one  of  its  linear  edges, 
which  in  the  use  of  the  ball  of  0.38  cal.  so  often  makes  it 
triangular.  In  a  single  instance  the  circular  outline  was 
preserved  without  modification  and  the  diameter  remained 
smaller  than  that  of  the  ball. 

Disintegrated  brain  matter  is  extruded  from  the  wound 
of  entrance  in  two  cases  out  of  three  in  the  aggregate 
number  taken  at  all  ranges.  At  contact,  it  is  of  excep- 
tional occurrence.  In  these  particulars,  as  in  variations  of 
amount  and  of  force  of  projection,  the  facts  observed  are 
the  same  as  in  the  use  of  the  ball  of  larger  calibre. 

The  smoke  stain  upon  the  skin  is  constant  at  a  range  of 
8'  or  less,  is  present  in  a  minority  of  cases  when  it  is  from 


256  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

one  foot  to  two  feet,  and  is  never  formed  when  it  exceeds 
that  distance.  The  limit  of  range  is  therefore  the  same  as 
in  case  of  the  ball  of  0.38  cal.  At  contact  there  is  usually 
a  trivial  staining  of  the  surface  which  was  exceptional  in 
the  former  instance.  At  a  range  of  i"  or  less  there  is  a 
distinctly  defined  smoke  area  from  i^/^"  to  2j4"  in  diame- 
ter with  possible  prolongations  or  more  distant  smudges ; 
at  3"  the  area  is  from  1^2"  to  2}^"  in  diameter  with  some- 
times an  additional  trace  to  an  equal  extent;  at  6"  to  8" 
the  area,  which  is  from  2"  to  2}^  in  diameter,  is  sharply 
limited;  at  one  foot,  the  area  is  reduced  to  i}4"  in  diam- 
eter ;  and  at  two  feet  there  is  no  longer  an  area  and  only  ex- 
ceptionally an  indefinite  trace.  In  general,  at  the  lesser  dis- 
tances the  traces  of  smoke  upon  the  surface  may  be  further 
extended,  while  at  the  longer  ranges  the  area  is  more  con- 
tracted and  more  sharply  defined  than  with  the  larger  ball. 

Burns  of  the  hair  or  skin  occur  within  a  range  of  6". 
At  contact  the  burning  of  the  cutaneous  edge  is  limited  to 
the  central  portion  of  the  woimd  which  is  directly  tra- 
versed by  the  ball.  In  the  one  case  observed  in  which  the 
wound  maintained  its  circular  outline  there  was  a  scorched 
as  well  as  a  smoked  area  of  }^"  as  there  would  have  been  in 
a  similar  wound  inflicted  at  a  perceptible  range.  The  hair 
when  exposed  may  be  slightly  singed  immediately  at  the 
point  of  entrance  either  at  its  ends  or  at  its  roots.  At  a 
range  from  14"  to  3"  the  black  area  is  from  }i"  to  }(" 
with  a  possible  additional  scorched  area  from  }i"  to  i". 
At  3"  or  6"  burning  is  not  invariable,  and  at  6"  it  is 
limited  to  the  cutaneous  edge  or  to  the  hair ;  at  7"  it  ceases 
altogether. 

The  presence  of  unburned  grains,  either  fixed  in  the  skin 
or  free  upon  its  surface,  is  noted  from  contact  to  a  range  of 


17 


258  IN7URIES    OF   THE    BRAIN   AND    MEMBRANES. 

three  and  one-half  feet  inclusive.  The  deposit  of  free  grains 
may  be  detected  upon  the  surface  of  the  skin  or  upon  the  un- 
derlying white  cloth  at  any  range  less  than  thirty  feet. 
These  limits  seem  to  be  absolute.  At  contact  the  ingraining 
of  the  skin  is  exceptional,  and  is  then  limited  to  the  margin 
of  the  wound.  At  a  range  of  1 "  and  less  it  is  confined  to  the 
black  area  of  less  than  ^"  in  diameter,  with  possibly  a  very 
few  isolated  grains  just  beyond  its  border;  at  3"  and  6"  it 
is  limited  to  the  extreme  smoke  area  of  i3/^"  to  6",  at  one 
foot  it  is  mainly  within  a  space  of  2;2",  but  is  extended  to 
a  distance  of  4"  and  even  6";  at  two  feet  there  is  less  in- 
graining  in  the  immediate  vicinity  of  the  wound,  but  the 
whole  area  is  not  smaller.  At  three  and  at  three  and  one- 
half  feet  the  number  of  grains  embedded  is  very  small,  per- 
haps not  more  than  two  or  three,  and  these  at  a  distance 
from  the  wound.  At  ranges  from  3"  to  two  feet,  the 
number  is  very  great,  and  probably  not  less  than  when  the 
ball  is  of  0.38  cal.  The  unburned  grains  which  remain 
free  at  ranges  less  than  3"  can  usually  be  detected  only 
upon  the  underlying  cloth;  at  ranges  of  3"  and  6"  they 
can  be  noted  in  the  smoke  area  with  those  which  are  em- 
bedded but  in  much  smaller  number.  At  ranges  from  one 
foot  to  three  feet  they  are  numerous,  and  beyond  that 
limit  they  are  few  and  at  a  distance  from  the  wound. 
The  range  at  which  unburned  powder  may  be  embedded  in 
the  skin  is  thus  somewhat  less  than  with  ball  of  0.38  cal., 
as  is  the  area  of  smoke  stain  or  of  burning,  but  the  number 
of  grains  and  the  area  which  they  cover  are  not  essentially 
different,  nor  is  either  the  range,  number,  or  area  of  those 
grains  which  are  left  free  upon  the  surface. 

The  lesions  of  the  subcutaneous  tissues  at  contact,  or  at 
ranges  of   1"  and  less,  are  indistinguishable  in  nature  and 


Fig.  io. — 0.32  Cal.     Range,  3".     Smoke  Area  and  Scorching  of  Skin;  Powder  Grains 
Apparently  all  Embedded. 


260  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

extent  from  those  produced  by  the  ball  of  0.38  cal.  At  3" 
there  are  less  staining  and  separation  of  the  scalp  layers, 
and  at  6"  traces  of  powder  are  no  longer  evident.  Frag- 
ments or  particles  of  lead  and  lead  stains,  as  with  the  larger 
calibre,  occur  at  all  ranges  and  with  equal  certainty  at  the 
longer  distances. 

Powder  grains  within  the  cranial  cavity  can  be  detected 
at  ranges  of  less  than  i",  and  at  contact — often  upon  the 
contiguous  surfaces  of  the  calvarium  and  dura  mater,  invari- 
ably in  the  brain  track,  and  sometimes  in  the  cutaneous 
wound  of  exit.  At  3"  the}'  can  be  usually  recognized,  but  at 
6"  it  is  probably  never  possible  to  discover  them  by  simple 
visual  inspection.  A  lead  stain  can  be  occasionally  distin- 
guished in  the  brain  substance,  either  with  or  without  the 
presence  of  grains  of  powder.  There  is  nothing  in  the 
extent  of  intracranial  staining  which  indicates  the  calibre 
of  ball. 

Fragments  of  bone  more  or  less  finely  comminuted  may 
be  carried  into  the  brain  to  all  distances  at  all  ranges,  and 
this  result  of  pistol-shot  fracture  of  the   cranium  has  no 
special  characteristics  with  balls  of  this  calibre 
0.44  cal. 

{(i)  Length  of  barrel,  6)4". 

(/;)  Length  of  barrel,  2}(''. 

vSame  cartridge. 

Diameter  of  ball,  0.429. 

Weight  of  ball,  236  grs. 

Weight  of  powder.  23  grs. 

Total  number  of  observations,  90. 
The   difference  in  penetrative  power   and   consequent 


262  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

effectiveness  of  different  weapons  of  this  calibre  is  so  great 
that  two  were  selected  as  types,  and  observations  made 
independently  for  each.  The  results  proved  that  corre- 
sponding or  appreciable  differences  did  not  exist  in  the 
lesions  of  soft  parts  nor  in  other  superficial  conditions,  and 
conclusions  have  been  formulated  from  the  consolidation 
of  the  two  series. 

The  wound  of  entrance,  while  exceptionally  as  minute 
(ye")  as  any  observed  from  balls  of  the  smallest  calibre,  is 
ordinarily  from  ^"  to  j-\",  and  occasionally  i<("  in  diameter. 
At  contact,  the  wound,  though  it  may  be  as  large  as  ^" 
when  circular  and  symmetrical,  does  not  exceed  in  length 
when  linear  those  inflicted  with  a  ball  of  0.38  cal.  In  the 
use  of  the  inferior  type  of  weapon,  in  which  penetration  of 
bone  often  fails,  the  size  of  the  wound  is  not  usually  in- 
creased. A  lead  stain  of  the  cutaneous  edge  is  of  frequent 
occurrence,  as  it  is  with  the  use  of  balls  of  other  calibres. 

The  extrusion  of  disintegrated  brain  matter  through 
the  external  wound  with  more  or  less  force  occurs  in  some- 
what more  than  half  of  the  whole  number  of  cases,  and  is 
observed  at  contact  or  at  one  hundred  feet  as  well  as  at 
the  intermediate  ranges. 

A  smoke  stain  upon  the  skin,  of  variable  extent,  is 
perceptible  in  a  minority  of  cases  at  contact,  but  it  is  al- 
ways faint.  At  3"  and  less  it  is  dense,  and  invariable,  with 
an  extent  of  2"  to  2}4",  and  a  possible  increase  to  4".  At 
6"  it  has  the  same  density  and  area,  but  ceases  to  be 
invariable.  At  one  foot  it  is  again  faint  and  of  still  more 
uncertain  occurrence.     At  two  feet  it  has  disappeared. 

The  hair  or  skin  is  burned  at  contact  or  at  a  range  of 
15"  or  less.  At  contact,  only  the  hair,  or  the  margin  of 
the  wound  to  an  extent  not  exceeding  yi  ",  will  be  involved. 


264  INJURIES    OF    THE    BRAIX    AND    MEMBRANES. 

At  a  range  from  ^2"  to  3'  inclusive,  a  black  area  of  y."  may 
be  formed,  or  the  skin  scorched  upon  one  aspect  of  the 
wound  or  concentrically  ^"  to  iX  ">  or  the  hair  burned  over 
an  area  of  2  "  or  less.  At  a  range  of  6"  the  skin  is  scorched 
in  a  majority  of  cases,  unless  protected  by  the  hair,  and 
at  7"  it  is  possible,  but  was  not  positive  in  any  of  the  obser- 
vations made.  At  one  foot  the  hair  may  be  slightly  singed, 
and  at  15"  it  is  of  only  exceptional  occurrence. 

Powder  is  ingrained  or  remains  free  upon  the  surface 
in  an  area  which  varies  to  some  extent  in  the  use  of  the  two 
types  of  pistol  of  this  calibre.  The  differences  are  not 
great  and  might  disappear  if  the  observations  were  suffi- 
ciently extended.  At  contact  with  the  inferior  weapon, 
some  free  grains  were  found  upon  the  underlying  cloth  in 
each  instance,  and  in  one  a  black  area  was  formed  about 
the  wound  of  entrance ;  while  with  the  better  weapon  no 
unburned  grains,  superficial  or  embedded,  were  perceptible 
in  either  of  the  observations  made.  At  a  range  of  >^'^ 
there  was  a  black  area  of  >^"  or  less  with  the  first  weapon, 
and  there  were  only  a  few  free  grains  upon  the  cloth  with  the 
second.  At  a  range  of  i"  many  grains  were  embedded  in 
an  area  of  i"  to  1^2 "  with  the  first  weapon  ;  and  only  a  black 
area  of  Yz",  or  an  area  of  larger  embedded  grains  of  i", 
was  formed  with  the  second.  At  a  range  of  3"  the  area  of 
embedded  grains  was  the  same,  i>4"  to  \i/i"  in  both.  At 
a  range  of  6"  the  area  of  embedded  grains  was  again  the 
same  in  both  weapons,  but  was  from  2"  to  2>^"  in  diameter. 
At  a  range  of  one  foot,  while  the  area  of  embedded  grains 
might  extend  to  4"+,  it  was  mainly  limited  to  3"X2". 
The  free  grains  were  the  more  numerous  when  the  inferior 
weapon  was  employed.  At  a  range  of  two  feet,  with  the 
better  weapon,  the  grains  were  still  embedded  in  the  larger 


^ 


Fig.  13.— 0.32  Cal.     Range,  2  ft.     Free  Powder  Grains,  Twelve  Embedded. 


266  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

proportion,  and  the  area  was  extended  to  five  inches.  At 
a  range  of  three  feet  the  grains,  which  were  about  one-half 
embedded  and  somewhat  less  numerous,  covered  the  whole 
side  of  the  face.  At  a  range  of  five  feet  few  appreciable 
grains  were  imconsumed,  of  which  not  more  than  ten  or 
twelve  were  likely  to  be  embedded.  At  six  feet  no  grains 
were  embedded  and  few  remained  free  upon  the  surface. 
At  ten  feet,  and  longer  ranges,  a  few  scattered  grains  upon 
the  face  or  underlying  cloth  were  of  uncertain  occurrence, 
and  at  twenty-five  feet  they  had  disappeared  altogether. 

The  subcutaneous  lesions  produced  at  contact  with 
the  more  efficient  pistol  of  0.44  cal.  are  more  extensive 
than  with  weapons  of  smaller  size  in  proportion  to  the  more 
extensive  cutaneous  wound  which  it  inflicts.  The  pistol  of 
this  calibre  of  inferior  type  has  no  greater  destructive 
effect  than  has  those  of  the  lesser  calibres.  At  ranges  of 
from  one  to  three  inches  no  more  extended  staining  of  the 
tissues  or  separation  of  the  layers  of  the  scalp  is  observed 
than  has  been  found  to  exist  with  the  use  of  0.38  cal.,  nor 
is  the  range  longer  in  which  they  occur. 

Powder  grains  are  carried  into  the  intracranial  cavity 
and  are  appreciable  at  the  same  ranges  and  in  the  same 
proportion  of  cases  as  with  0.32  or  0.38  cal. 

The  comminuted  bone  is  driven  into  the  brain  at  all  ran- 
ges as  with  other  calibres,  and  in  somewhat  greater  amount. 

0.22  cal. 
Length  of  barrel,  3". 
Diameter  of  ball,  0.230". 
Weight  of  ball,  45  grs. 
Weight  of  powder,  1 5  grs. 
Number  of  observations,  200. 


,,^ 


Fig.  14.— 0.32  Cal.     Range,  3  ft.     Free  Powder  Grains. 


268  INJURIES    OF   THE   BRAIN    AND    MEMBRANES. 

The  superficial  conditions  presented  in  wounds  inflicted 
by  this  smaller  missile  are  much  more  variable  than  when 
the  ball  has  been  of  either  of  the  larger  calibres  previously 
considered ;  but  the  variations  are  within  definite  and  com- 
paratively narrow  limits. 

The  wound  of  entrance,  while  still  circular  and  smaller 
than  the  ball,  save  in  the  exceptional  instances  noted  for 
the  larger  calibres,  is  of  relatively  and  often  of  absolutely 
greater  diameter  than  the  average  ascertained  for  balls  of 
0.32  or  even  0.38  cal.  The  diameter,  which  is  within  the 
same  limits  of  ^"  to  -^",  is  perhaps  oftener  as  large  as  yi" 
than  in  them.  At  contact  the  wound  ceases  to  have  char- 
acteristics which  when  the  ball  was  larger  habitually  dis- 
tinguished it  from  those  inflicted  at  perceptible  ranges. 
In  fifteen  out  of  eighteen  cases  the  wound  was  small  and 
circular,  and  from  -^"  to  i"  in  diameter;  in  the  three  re- 
maining it  was  linear  and  patulous,  i"  in  length  in  two 
of  them,  and  /4"X}i"  with  lacerated  and  everted  edge 
in  the  other.  Subcutaneous  laceration  occurred  in  but  a 
single  one,  though  blackening  of  some  plane  of  tissue  was 
invariable. 

Disintegrated  brain  matter  is  extruded  from  the  wound 
of  entrance  with  much  less  frequency  than  in  the  use  of 
balls  of  larger  calibre,  and  never  with  the  same  violence 
which  with  them  has  been  sometimes  noted  at  moderate 
ranges. 

The  smoke  stain  upon  the  skin,  which  was  rarely  ob- 
served at  ordinarily  firm  contact  in  the  use  of  balls  of  0.32 
or  0.38  cal.,  is  present  in  three  cases  out  of  four  when  the 
ball  is  of  0.22  cal.  In  three-fourths  of  these  again  it 
covers  an  area  >4"  in  diameter,  and  in  the  remainder  its 
extent  varies  from   }i"  to   }^".     At    imperfect  contact  it 


270  INJURIES    OF    THE    BRAIN   AND    MEMBRANES. 

often  happens  that  a  dense  smoke  area  of  Yz"  and  a  clear 
interval  of  the  same  or  somewhat  greater  extent  are  in- 
cluded in  a  more  or  less  distinct  or  complete  outer  ring  of 
smoke,  with  an  aggregate  diameter  of  i>^"  to  3".  At  a 
range  of  i"  the  smoke  area  extends  from  i"to4"  in  its 
longest  diameter,  but  is  usually  from  lYz"  to  2>^".  At  3" 
and  at  6"  its  average  remains  the  same,  but  its  density  is 
less,  with  perhaps  no  definite  area.  At  a  range  of  one 
foot,  as  in  case  of  0.32  cal.,  there  is  but  a  faint  trace  of 
smoke  or  none  at  all,  and  beyond  that  limit  it  is  absent 
altogether. 

Burning  or  scorching  of  the  skin  and  hair  occurs  at 
contact  and  is  limited  to  a  range  of  3".  At  contact  in 
fifteen  out  of  sixteen  cases  the  margin  of  the  wound 
was  burned  or  the  skin  was  scorched  over  a  circular 
area  of  y(^"  to  y^,"  or  in  some  instances  upon  one  side 
only.  At  I "  the  skin  was  scorched  over  an  area  of  ■^"  to 
i",  or  the  hair  was  burned.  At  3"  the  skin  was  occasion- 
ally scorched  for  similar  distances,  or,  as  more  frequently 
happened,  the  hair  was  singed,  and  in  many  instances  no 
burn  of  any  kind  or  degree  existed.  At  greater  distances 
not  even  the  edge  of  the  wound  was  burned,  though  it 
was  often  lead  stained. 

The  existence  of  unburned  grains  of  powder,  whether 
embedded  in  the  skin  or  lying  free  upon  its  surface,  is  not 
absolutely  constant  at  any  range;  and  in  any  case  the 
grains  are  comparatively  few  in  number.  KX.  contact,  as 
occurs  with  the  larger  calibres,  they  are  practically  absent, 
and  this  even  though  the  wound  of  entrance  is  usually 
contracted.  In  a  single  instance  one  or  two  grains  were 
found  far  away  upon  the  surface.  At  i"  in  a  major- 
ity of  cases  a  moderate  number  of  grains  are  embedded 


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272  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

in  an  area  of  %"  to  i";  in  other  cases  from  six  to  ten 
grains  or  even  fewer  may  be  sparsely  scattered  somewhat 
farther  away  from  the  wound;  and  in  others  still  there 
are  no  grains  embedded  and  none  upon  the  surface.  At 
3"  the  unburned  grains  are  all  embedded  in  an  area  of  ^" 
to  1%",  and  in  one  case  no  grains  remained  unconsumed. 
At  6"  the  area  of  implantation  is  extended  to  i"  or 
2"  in  half  the  cases,  and  in  the  other  half  there  may 
be  not  more  than  five  or  six  grains  altogether  at  un- 
certain distances  from  the  wound.  At  these  ranges, 
from  contact  to  six  inches,  appreciable  unburned  grains 
free  upon  the  surface  are  exceptional;  such  as  have  es- 
caped combustion,  if  not  fixed  in  the  skin,  are  too  few 
and  too  distant  to  be  distinguishable.  At  one  foot  and  two 
feet  there  were  a  very  limited  number  of  embedded 
grains  in  half  the  cases  examined,  but  in  all  save  one 
there  were  free  unburned  grains  within  an  area  of  3"  or 
less.  At  three  feet  and  more  no  grains  are  embedded, 
and  the  few  lying  upon  the  surface  are  widely  scattered, 
often  over  the  whole  side  of  the  face  and  forehead.  At 
twenty-five  feet  or  more,  unburned  grains  are  no  longer 
discoverable  either  upon  the  surface  of  the  head  or  face  or 
upon  the  underlying  cloth. 

The  subcutaneous  lesions  are  practically  confined  to 
a  range  of  i "  and  less.  At  contact  the  blackened  area 
may  be  either  upon  or  beneath  the  temporal  fascia,  and 
measure  from  %,"  to  2"  in  diameter.  The  muscular  tissue 
is  often  additionally  powder  stained  and  smoked  through 
its  substance,  and  the  osseous  surface  similarly  discolored, 
but  laceration  is  infrequent.  At  i"  the  muscle  is  stained 
in  three-fourths  of  the  cases  examined,  but  the  more  super- 
ficial   layers   are   unaffected.     At    3"    there   is   ordinarily 


274  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

nothing  more  than  a  discoloration  of  the  ball  track, 
though  grains  of  powder  may  be  sometimes  detected  in  its 
course  or  upon  the  osseous  margin,  and  a  lead  stain  upon 
the  temporal  fascia  is  possible.  At  6"  and  more  there  are 
no  evidences  of  the  passage  of  the  ball  through  the  exter- 
nal parts  outside  its  track,  except  for  the  not  infrequent 
presence  of  particles  or  fragments  of  lead. 

Grains  of  powder  in  the  intracranial  cavity  are  de- 
monstrable at  a  range  of  i"  or  less,  and  may  be  excep- 
tionally noted  even  at  6".  The  amount  of  powder  carried 
into  the  brain  substance  is  small,  and  it  penetrates  the 
contiguous  cerebral  lobe  only  to  a  moderate  distance.  In 
one  case  at  a  range  of  6"  only  three  grains  were  dis- 
tinguishable. At  contact  the  contiguous  surfaces  of  cal- 
varium  and  dura  may  be  dotted  with  grains  of  powder 
over  an  area  of  i"  or  more,  as  in  observations  made  with 
larger  calibres  of  ball. 

The  detection  of  more  or  less  finely  comminuted  frag- 
ments of  bone  in  the  course  of  the  ball  through  the 
brain  is  possible  at  all  ranges,  but  as  the  osseous  wound  is 
smaller  the  number  is  necessarily  less  than  when  the 
calibre  is  greater.  It  can  probably  not  be  recognized  be- 
yond the  median  cerebral  fissure. 

In  formulating  so  great  a  number  of  experimental  re- 
sults, it  has  been  thought  unadvisable  to  present  each 
observation  in  detail,  since  a  procedure  so  laborious  and  a 
record  so  voluminous  would  be  attended  by  no  corre- 
sponding advantage.  The  individual  differences  for  each 
point  to  be  determined  have  been  inconsiderable;  and  by 
noting  and  recording  the  limits  of  variation  in  repeated 
instances  needless  repetition  has  been  avoided. 

The    notation  of    corroborative    experiments  upon  the 


2/6  INJURIES   OF    THE    BRAIN   AND    MEMBRANES. 

trunk  and  extremities  was  discontinued  beyond  those 
made  with  balls  of  0.38  caL,  as  peculiarities  in  effect, 
though  slight,  still  existed,  and  conclusions  as  to  the  head 
might  be  open  to  just  criticism  if  based  upon  them. 

The  results  obtained  from  these  observations  of  pistol- 
shot  wounds  of  the  head,  made  at  corresponding  ranges 
with  balls  of  different  calibres,  have  been  so  far  con- 
densed that  no  necessity  exists  for  further  generalization ; 
but  for  convenience  of  comparison  they  may  be  somewhat 
abbreviated  and  differently  formulated. 

The  wound  of  entrance,  with  all  calibres  of  ball  and 
at  all  ranges,  except  at  contact  or  in  certain  instances 
in  which  impact  is  made  upon  a  cranial  curve,  is  smaller 
than  the  ball.  Its  diameter  varies  from  yL.''  to  -^^" ,  and  its 
average  is  the  same  for  each  calibre  except  0.44,  for  which 
it  is  perceptibly  larger  and  for  which  a  maximum  of  ]^" 
may  be  attained. 

Disintegrated  brain  matter  may  be  forced  into  the 
wound  of  entrance,  or  may  be  extruded  from  it  with  more 
or  less  violence,  at  all  ranges  with  all  calibres  of  ball.  It 
occurs  in  rather  more  than  half  the  cases  in  the  use  of 
0.32,  0.38,  or  0.44  cal.,  and  in  rather  less  than  half  the 
number  with  0.22  cal. 

The  staining  of  the  skin  by  smoke  at  different  ranges 
varies  in  its  occurrence  and  extent  with  the  use  of  differ- 
ent calibres  of  ball. 

{a)  0.38  cal.  A  smoke  stain  upon  the  skin  never  oc- 
curs at  firm  contact;  is  invariable  at  a  range  of  6"  or  less — 
except  possibly  when  intercepted  by  thick  hair,  or  when 
in  rare  instances  a  lacerated  wound  is  inflicted  at  a  range 
slightly  beyond  contact;  is  of  uncertain  presence  at  a 
range  of  from  one  foot  to  two  feet ;  and  is  absent  at  greater 


278  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

distances.  At  a  range  of  1"  and  less  it  covers  an  area  of 
i}("  to  2^2",  and  at  a  range  of  3''  an  area  from  3"  to  5'  in 
diameter,  and  at  both  ranges  includes  a  black  area  which 
is  the  result  of  smoke,  burn,  and  the  ingraining  of  finely 
divided  grains  of  powder.  At  a  range  of  6"  it  covers  an 
area  of  2^4"  to  4",  and  at  a  range  of  from  one  foot  to  two 
feet  either  covers  a  well-defined  area  of  1"  or  is  faintly 
diffused  over  a  space  of  $"  to  6". 

(d)  0.32  cal.  A  smoke  stain  is  usually  perceptible  at 
contact,  forms  a  distinct  area  from  1%"  to  2)4"  in  extent 
at  any  range  less  than  6",  infrequently  occurs  and  forms 
an  area  of  1)4"  at  one  foot,  and  is  only  occasionally 
present  as  a  mere  trace  at  two  feet. 

(c)  0.44  cal.  A  smoke  stain  occurs  at  contact  and  at 
ranges  less  than  two  feet.  At  contact  and  at  one  foot  it  is 
faint  and  inconstant.  At  3"  and  less  it  is  dense,  covers  an 
area  from  2"  to  2  j4"  in  diameter  and  is  invariable.  At  6"  it 
has  the  same  density  and  area,  but  ceases  to  be  invariable. 

(d)  0.22  cal.  A  smoke  stain  covers  an  area  of  ^"  to 
}("  in  diameter  in  75  per  cent,  of  cases  at  contact ;  may  form 
a  double  ring  of  i>^"  to  3"  aggregate  diameter  at  imper- 
fect contact ;  extends  over  a  space  from  i "  to  4"  in  diam- 
eter at  a  range  of  i"  to  6";  exists  only  as  a  faint  trace  at 
one  foot,  and  is  absent  altogether  at  greater  distances. 

Burning  of  the  hair  or  skin  occurs  at  contact  with  all 
calibres  and  is  limited:  with  0.44  cal.  to  a  range  of  15", 
with  0.38  cal.  to  a  range  of  10",  with  0.32  cal.  to  a  range 
of  6",  and  with  0.22  cal.  to  a  range  of  3".  At  the  extreme 
limits  it  is  confined  to  the  edge  of  the  wound  or  to  the 
hair,  and  at  intermediate  ranges  it  additionally  includes 
the  burning,  which  is  a  factor  in  the  production  of  the 
black  area,  or  a  still  more  extended  scorching  of  the  skin. 


Fig. 


-.--.44  Ca,.     Range,  .  ft.     Area  of  Powder  Grains,  Mainly  Embedded. 


28o  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

The  black  area  which  is  formed  at  a  range  of  Yz"  to  6" 
with  the  0.38  cal.,  or  of  Yz"  to  3"  with  the  0.32  cal,,  is 
from  y%"  to  y^"  in  diameter.  The  scorching  of  the  skin  in 
the  use  of  the  0.38  cal.  occurs  in  an  area  of  i"  to  i^",  and 
of  the  0.32  cal.  in  an  area  of  y%"  to  i".  In  a  suicidal  case 
reported  in  the  accompanying  series  the  burned  and 
scorched  area  extended  to  a  distance  of  nearly  2"  (0.32 
cal.).  The  black  area  with  0.22  or  0.44  cal.  is  limited  to 
y%"  and  the  scorching  of  the  skin  to  i"  and  \y^"  re- 
spectively. 

Embedded  grains  of  powder  when  the  cartridge  is  of 
0.38  cal.  may  be  detected  at  ranges  from  Yz"  to  four  feet, 
and  unburned  grains  upon  the  surface  at  ranges  from  6" 
to  just  within  thirty  feet.  The  embedded  grains  may  be 
confined  to  the  composite  black  area,  or  cover  a  space  of 
6",  and  at  the  longer  ranges,  from  three  to  four  feet,  there 
may  be  none,  or  the  number  may  vary  from  one  or  two  to 
forty.  The  superficial  free  grains  are  numerous  at  ranges 
of  from  one  to  six  feet  and  may  cover  the  whole  side  of  the 
face  and  neck ;  at  longer  ranges  they  may  be  absent,  or 
may  be  not  more  than  one  or  two  in  number.  The  em- 
bedded grains  outnumber  those  which  are  free  upon  the 
surface  at  ranges  less  than  two  feet,  are  in  variable  pro- 
portion at  that  limit,  and  are  fewer,  if  thej^  exist  at  all,  at 
longer  ranges.  When  the  cartridge  used  is  of  0.32  cal. 
grains  of  powder  are  embedded  at  ranges  from  contact  to 
three  and  one-half  feet  inclusive,  and  are  left  free  upon  the 
surface  at  ranges  from  3"  to  twenty-five  feet.  At  a  range 
of  less  than  3"  free  grains  may  be  sometimes  discovered 
in  the  hair  or  upon  the  underlying  cloth.  The  number  of 
unburned  grains  is  not  generally  less  than  with  the  o.  38  cal. , 
and  the  areas  which  thev  cover  and  their  relative  numeri- 


0f 


'  ..'  wC'  - 


^Pr 


Fig.  21.— 0.44  Cal.     Range,  3  ft.    Free  and  Embedded  Powder  Grains. 


282  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

cal  proportions  are  the  same.  When  the  cartridge  is  of 
0.44  cal.  the  areas  and  relative  numbers  of  embedded  and 
superficial  grains  vary  slightly  with  the  type  of  pistol 
used.  The  ranges  at  which  the}^  are  ingrained  extend 
from  yi"  to  five  feet,  and  the  ranges  at  which  they  are  de- 
posited upon  the  surface  of  the  skin  or  upon  neighboring 
objects  from  contact  to  twenty-five  feet.  At  ranges  of 
less  than  3"  the  proportion  of  embedded  grains  is  greater 
with  the  inferior  weapon,  and  at  ranges  of  more  than  6" 
is  greater  when  the  weapon  is  of  the  more  efficient  type. 
The  areas  covered  by  unburned  grains  are:  at  ranges  of 
3"  and  less,  Yi"  to  lYz" \  at  a  range  of  6",  i}^"  to  3";  at 
a  range  of  one  foot,  2>4"  to  4";  and  at  ranges  of  three 
to  five  feet  they  include  the  whole  side  of  the  face. 
When  the  cartridge  is  of  0.22  cal.  the  unburned  grains 
are  fewer  in  number  and  inconstant  at  all  ranges.  They 
may  be  observed  from  contact  to  a  range  somewhat  less 
than  three  feet  for  those  which  are  embedded,  and  some- 
what less  than  twent3'-six  feet  for  those  which  are  free. 
The  embedded  grains  are  found  in  an  area  of  less  than  2", 
and  those  upon  the  surface  within  an  area  of  less  than  3". 
At  ranges  of  more  than  three  feet  the  superficial  grains 
may  be  sparsely  scattered  over  the  whole  side  of  the  face 
and  forehead. 

The  subcutaneous  lesions  with  all  calibres,  at  con- 
tact, include  laceration  of  the  tissues  from  the  explosive 
effect  of  the  bullet,  and  their  blackening  by  smoke,  burn- 
ing, and  power  infiltration,  together  with  some  separation 
of  the  layers  of  the  scalp,  which  usually  occurs  at  the  level 
of  the  temporal  fascia.  The  laceration  involves  an  area  of 
1"  to  3".  At  ranges  of  1"  to  3",  lesions  are  confined  to 
blackening  of  the  tissues  below  the  occipito-frontal  apo- 


284  INJURIES    OF    THE    KRAIX    AND    MEMBRANES, 

neurosis  or  temporal  fascia,  or  of  the  margin  of  the 
osseous  entrance,  over  an  area  of  %"  to  2.  At  or  beyond 
ranges  of  3"  there  is  only  an  exceptional  staining  of  the 
tissues  outside  the  track  of  the  ball.  The  extreme  limit 
of  range  at  which  these  changes  occur  is  for  0.38  cal.  of 
ball  6",  though  possibly  a  few  grains  of  powder  may  be 
carried  into  the  temporal  muscle  at  one  foot;  for  0.32  cal., 
not  to  exceed  3";  for  0.44  cal,  6";  and  for  0.22  cal.  not  ex- 
ceeding i".  Fragments  of  lead  and  lead  stains  are  fre- 
quent at  all  ranges  and  with  all  calibres  of  ball. 

Grains  of  powder  appreciable  upon  simple  visual  in- 
spection may  be  carried  through  the  osseous  wound  into 
the  intracranial  cavity  with  all  calibres  at  contact  and 
within  a  possible  range  of  6".  At  contact  they  may  be 
invariably  detected,  and  perhaps  with  equal  certainty  at  a 
range  of  i".  At  a  range  of  3"  their  detection  becomes 
doubtful,  and  at  6"  only  exceptionally  possible.  At  con- 
tact they  may  be  found  upon  the  contiguous  surfaces  of 
the  calvarium  and  dura,  and  in  large  number  through  the 
whole  length  of  the  cerebral  track  and  perhaps  even 
through  the  external  wound  of  exit.  At  a  range  of  i" 
they  are  likely  to  be  confined  to  the  track  through  the 
contiguous  cerebral  lobe;  and  at  3"  or  6",  if  they  exist  at 
all,  they  are  few  and  isolated  and  near  the  osseous  woimd 
of  entrance.  Their  number  seems  to  be  independent  of 
the  calibre  of  the  ball,  except  at  contact,  when  the  corre- 
spondence is  direct. 

Fragments  or  particles  of  bone  more  or  less  fineh' 
comminuted  are  carried  into  the  brain  track  with  all 
calibres  and  at  all  ranges.  The  differences  observed 
have  no  essential  or  diagnostic  importance. 

These    generalizations    have    been    made    sufficiently 


286  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

comprehensive  to  include  conceivable  variations  in  the 
effects  of  different  weapons  and  cartridges  upon  different 
subjects  under  ordinary  circumstances.  They  directly 
summarize  the  average  results  obtained  from  the  use  of 
factory-filled  cartridges  of  the  usual  type  at  specified 
ranges.  There  are  differences  to  be  reckoned  with  in  indi- 
vidual cartridges  and  in  individual  weapons,  as  there  are 
in  individual  subjects  and  in  attendant  conditions.  Car- 
tridges and  pistols  of  the  same  calibre  vary  in  their 
eff'ects,  not  onh^  as  they  are  the  product  of  different 
makers,  but  as  they  are  of  different  types  and  lengths, 
and  each  may  have  even  individual  peculiarities.  Atmos- 
•pheric  conditions  may  aff'ect  cutaneous  indications,  as  may 
accidental  conditions  of  the  surface,  or  as  may  physical 
properties  dependent  upon  age,  sex,  or  congenital  confor- 
mation. Smoke  will  not  be  so  densely  deposited  upon  the 
surface  in  dry  as  in  damp  weather;  the  hair  which  is  wet 
or  smooth  will  not  be  so  readily  burned  as  will  the  hair 
which  is  dry  and  fluffy;  the  skin  which  is  tough  and  re- 
sistant, or  which  is  covered  by  thick  hair,  will  not  be  so 
closely  ingrained  with  powder  as  skin  which  is  of  softer 
texture  or  which  is  unprotected ;  and  the  pistol  of  antique 
fashion  or  the  cartridge  which  is  old  or  made  of  inferior 
powder  will  not  have  the  same  penetrative  pov.-er,  or  oc- 
casion an  external  wound  having  the  same  characters,  as 
will  the  products  of  most  recent  manufacture.  It  is  not  to 
be  expected,  therefore,  that  a  ball  of  given  calibre  dis- 
charged at  a  given  range  will  in  every  instance  and 
under  all  circumstances  produce  exactly  the  same  super- 
ficial lesions,  or  occasion  precisely  the  same  extent  of 
cutaneous  change  from  more  or  less  perfect  combustion 
of    the    explosive;    but    these    variations    are    still    com- 


288  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

paratively  slight,  and  can  be  estimated  with  sufficient 
exactitude. 

The  averages  which  have  been  reached  in  the  measure- 
ment of  the  degree  and  extent  of  superficial  lesions  were 
established  primarily  for  pistols  and  cartridges  of  the 
highest  grade  in  use  for  other  than  target  purposes;  but 
in  the  instance  of  each  calibre  a  sufficient  number  of  sub- 
stitutions was  made  to  demonstrate  resulting  variations 
in  effect  at  practicable  ranges.  vSuch  variations  were  gen- 
erally trivial.  The  influence  exerted  by  natural  or 
accidental  differences  in  the  physical  properties  of  the 
external  parts,  while  often  appreciable  and  sometimes 
considerable,  was,  in  the  great  number  of  observations 
made,  still  insufficient  materially  to  modify  the  general 
conclusions  as  originally  formulated.  In  all  essential  par- 
ticulars these  may  be  regarded  as  established  truths,  so 
far  as  absolute  general  laws  may  be  deduced  from  an 
aggregation  of  individual  instances. 

The  characteristics  of  the  external  wound  of  exit  are 
in  general  too  well  defined  to  demand  formal  or  extended 
consideration.  This  wound  is  usually  larger  and  more 
extensively  lacerated,  and  contains  a  greater  amount  of 
disintegrated  cerebral  and  subcutaneous  tissue,  than  that 
of  entrance.  Its  margin  is  everted,  and  everted  osseous 
fragments  may  often  be  detected  before  or  after  its 
enlargement  for  more  thorough  examination.  The  ad- 
jacent cutaneous  surface  is  devoid  of  marks  of  flame, 
smoke,  or  powder.  These  conditions  are  largely  indepen- 
dent of  range  or  calibre,  but  if  calibre  is  large  and  range 
approximates  contact,  the  destructive  effects  of  the  ball  at 
exit  will  be  emphasized,  and  unburned  powder  which  has 
been  driven  through  the  brain  may  be  found  through  and 


19 


290  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

even  at  the  surface  of  the  wound.  If  in  any  case  doubt 
may  conceivably  exist,  it  may  be  resolved  by  comparison 
with  the  wound  of  entrance  or  by  examination  of  the 
osseous  lesion. 

The  question  is  pertinent  as  to  how  far  lesions  and 
indications  produced  in  the  post-mortem  state  correspond 
with  those  which  are  incident  to  traumatisms  in  the  liv- 
ing subject.  Differences  undoubtedly  exist,  but  they  are 
manifest  rather  in  the  extent  of  such  changes  than  in  the 
range  at  which  they  occur.  In  a  case  of  suicide,  Xo. 
CXXXIX.  of  the  annexed  series  of  histories,  in  which  the 
true  skin  was  charred  through  its  entire  thickness,  not 
only  the  degree  but  the  superficial  extent  of  burn  was 
greater  than  in  any  of  the  cadaveric  observations  made, 
but  it  was  still  within  the  determined  limit  of  distance 
from  the  wound.  In  general,  burning  of  the  skin  occurs 
within  the  same  limit  of  range,  and  is  confined  to  the 
same  area,  upon  the  living  as  upon  the  dead  subject;  but 
while  upon  the  cadaver  it  is  no  more  than  a  mere  staining 
of  the  surface,  or  possibly  a  destruction  of  the  epidermis, 
during  life  the  true  skin  may  be  involved  and  the  whole 
structure  be  desiccated  and  hardened.  The  number  of 
grains  of  powder  embedded  in  the  skin  might  very  con- 
ceivably differ  with  the  varying  conditions  of  life  and 
death,  but  the  number  of  grains  deposited  upon  the  sur- 
face, or  the  occurrence  of  smoke  stain,  which  depend 
solely  upon  the  perfection  of  combustion  within  given 
ranges,  should  be  the  same  in  either  event.  An  exact 
appreciation  of  such  differences  would  demand  the  clinical 
study  of  a  vast  number  of  cases  in  which  the  antecedent 
conditions  of  injury  could  be  accurately  determined;  and 
which,  if  it  were  possible,  would  obviate  the  necessity  for 


292  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

post-mortem  experimentation.  The  instances  of  gunshot 
wounds  of  the  head  included  in  the  accompanying  series  of 
intracranial  injuries  suggest  no  greater  discrepancies  in 
superficial  appearances  than  have  been  indicated  when 
such  wounds  are  inflicted  after  death. 

The  enumerated  alterations  suffered  by  the  external 
soft  parts,  in  structure,  or  appearance,  are  not  equally  con- 
stant factors  in  the  estimation  of  calibres  or  ranges.  The 
more  or  less  forcible  extrusion  of  brain  substance  through 
the  external  wound,  or  the  projection  of  bone  fragments 
through  the  cerebral  track  of  the  ball,  have  in  this  regard 
no  diagnostic  value,  since  they  are  possible  at  all  ranges 
with  balls  of  all  calibres.  The  deposition  of  unburned 
grains  of  powder  upon  the  skin  or  surrounding  surfaces, 
though  of  great  importance  when  observed,  is  probably  in 
the  great  majority  of  instances  in  which  it  has  occurred 
imavailable  as  a  means  of  determining  either  of  those 
points  in  diagnosis.  They  are  so  readily  displaced  and 
lost  upon  the  surface  of  the  earth  or  elsewhere,  and  the 
body  is  so  certain  to  have  been  disturbed  before  expert 
examination  can  be  made,  that  their  recognition  can  be 
scarcely  more  than  fortuitous,  even  in  the  cases  in  which 
they  have  been  most  abundantly  precipitated.  So,  too, 
the  powder  grains  which  have  been  driven  into  the 
cerebral  substance  by  the  force  of  the  explosion,  and  are 
readily  recognizable  in  cadaveric  experimentation,  are  so 
concealed  by  intracerebral  hemorrhage  that  they  are  more 
than  likely  to  escape  detection.  The  smoke  stain  is  very 
generally  washed  away,  either  by  external  hemorrhage  or 
by  the  application  of  water  in  a  sometimes  misguided 
effort  to  render  the  appearance  of  the  wounded  man  pre- 
sentable upon  the  arrival  of  the  surgeon  or  of  the  under- 


294  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

taker.  The  original  characters  of  the  external  wound, 
finally,  are  not  infrequently  changed  in  an  early  attempt  at 
exploration  and  their  significance  is  lost.  Notwithstand- 
ing the  slender  probability  that  certain  characteristic 
conditions  of  pistol-shot  wounds  which  have  been  specified 
can  be  utilized  for  determining  the  circumstances  under 
which  they  have  been  produced,  it  may  well  happen  in 
any  case  that  some  one  of  them  may  remain  sufficiently  in 
evidence  to  make  clear  an  otherwise  doubtful  history. 
Other  conditions  of  such  wounds  and  attendant  lesions  of 
the  skin  which  have  been  subjected  to  experimental  inves- 
tigation in  the  cadaver  may  be  reasonably  expected  to 
afford,  in  every  instance,  either  positive  or  negative 
evidence  of  the  size  of  the  ball,  or  of  its  range.  The 
superficial  wound  of  entrance,  though  liable  to  surgical 
interference  and  alteration  prior  to  observance  of  its 
original  characteristics,  is  oftener  left  intact  for  proper 
medico-legal  examination;  or,  as  it  may  chance,  the  pecu- 
liarities of  the  primary  wound  may  be  discerned  through 
the  secondary  changes  which  have  been  made  in  its  ex- 
tent and  conformation.  The  burning  of  the  hair  or  skin 
involves  structural  changes,  and,  however  trivial  it  may 
be,  its  traces  can  hardly  disappear  before  opportunity  is 
afforded  for  their  discovery.  The  grains  of  powder  which 
are  fully  embedded  in  the  skin  can  be  removed  only  with 
difficulty  and  by  direct  design,  and  their  presence  or  ab- 
sence must  have  a  definite  value  in  the  estimate  of  every 
case  which  demands  investigation.  The  subcutaneous 
lesions  of  the  scalp,  if  they  exist  outside  of  the  track  of 
the  ball,  involve  structural  changes  which  cannot  be  alto- 
gether obscured,  even  by  inexpert  examination  or  explora- 
tion of  the  wound. 


MEDICO-LEGAL    RELATIONS.  295 

It  must  not  be  expected  that  typical  cases  of  pistol-shot 
wound  will  be  often  encountered  in  which  there  will  be  a 
complete  and  symmetrical  presentation  of  all  the  possible 
superficial  alterations  which  indicate  the  range  at  which 
they  were  inflicted  or  the  calibre  of  the  ball.  Conclu- 
sions must  be  reached  here  as  on  other  lines  of  surgical 
inquiry,  from  the  study  not  of  complete  pictures,  but  of 
fragments,  and  may  be  as  positive  as  the  much-quoted 
results  which  have  been  similarly  attained  in  the  field  of 
comparative  anatomy.  A  single  indication  may  be  all 
that  is  necessary.  The  fact  that  the  skin  has  been 
scorched  is  sufficient  evidence  that,  whatever  the  calibre  of 
the  ball,  the  range  of  fire  has  been  not  more  than  six 
inches,  just  as  the  ingraining  of  the  skin  with  powder  is 
that  it  has  not  been  more  than  five  feet.  Confirmation  is 
probable  through  the  presence  or  absence  of  some  other 
indication,  but  without  it  the  single  fact,  uncontroverted, 
remains  sufficient. 

Indications  of  range  and  calibre  may  exist  which  are 
of  apparently  contradictory  import.  Their  reconciliation 
is  probably  always  possible  and  involves  the  recognition 
of  the  established  limits  within  which  their  variations  may 
legitimately  occur,  and,  it  may  be,  some  experience  in  their 
observation.  The  difficulties  which  such  cases  present 
are  not  insuperable,  and  not  usually  greater  than  those 
incident  to  the  solution  of  other  medico-legal  problems. 

It  is  scarcely  possible  to  overestimate  the  medico-legal 
importance  which  attaches  to  these  anatomical  considera- 
tions connected  with  the  infliction  of  pistol-shot  wounds 
of  the  head.  The  instances  in  which  the  ball  has  passed 
quite  through  both  cranium  and  soft  parts,  and  been 
absolutely  lost,  or  in  which  the  distance  it  has  traversed 


296  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

can  be  gauged  only  by  the  nature  of  the  wound  which  it 
has  inflicted,  or  by  the  traces  it  has  left  upon  the  surface, 
are  of  great  frequency.  Its  size  or  its  range,  thus  indi- 
rectly determined,  may  perhaps  solve  the  question  of 
accident,  suicide,  or  homicide ;  and  the  vindication  of  in- 
nocence or  the  punishment  of  guilt  may  rest  solely  upon 
the  possibility  of  fixing  with  precision  the  nature  and 
extent  of  the  superficial  lesions,  and  upon  the  correct 
interpretation  of  the  indications  which  they  afford. 

The  grave  responsibility  incurred  by  the  expression 
of  expert  opinion  in  cases  of  known  or  suspected  homi- 
cide can  be  justifiably  assumed  only  after  rigorous  inves- 
tigation and  careful  consideration  of  all  the  anatomical 
facts  and  their  comparison  with  established  data.  Ca- 
daveric observations,  if  practicable,  might  well  be  made 
with  the  pistol  which  has  been  the  instrument  of  death, 
and  with  cartridges  similar  to  the  one  it  carried ;  but  it  is 
not  certain  that  more  definite  ground  for  opinion  will  be 
found  in  special  and,  it  may  be  assumed,  limited  experi- 
mentation than  in  the  comprehensive  series  of  observations 
which  have  been  here  collated,  though  its  results  might 
conform  more  closely  to  the  technicalities  of  judicial  re- 
quirement. If  such  special  experiments  are  to  be  under- 
taken for  the  elucidation  of  a  particular  case,  an  adequate 
number  of  heads  should  be  assured,  the  use  of  which  may 
be  economized  by  accepting  data  already  acquired  in  order 
to  limit  the  field  of  special  inquiry.  The  effects  of  balls 
upon  paper  targets  are  not  admissible  in  evidence,  as 
they  are  not  comparable  with  those  which  are  observed 
upon  the  human  skin,  and  body  shots  at  the  same  range 
are  not  precisely  the  same  in  their  characters  as  those  in- 
flicted upon  the  head.     As  in  no  case  except  with  balls  of 


MEDICO-LEGAL    RELATIONS.  297 

the  smallest  calibre  can  more  than  two  or  three  observa- 
tions be  made  upon  the  same  head,  and  if  the  ball  is  of  large 
calibre  and  is  fired  at  short  range  probably  not  more  than 
a  single  one,  and  as  observations  must  be  largely  multiplied 
to  justify  positive  conclusions,  it  follows  that  unless  ana- 
tomical material  is  fully  at  command,  it  is  ordinaril}-  safer 
to  interpret  the  phenomena  presented  in  a  given  case  by  a 
comparison  with  the  aggregate  results  of  previous  clinical 
and  experimental  experience.  In  case  of  wounds  inflicted 
by  weapons  which  are  now^  of  unusual  calibre,  as  0.30  or 
0.25,  it  will  be  safe  to  make  the  ascertained  effects  of  the 
approximate  standard  calibre  the  basis  of  comparison.  The 
range  at  which  with  a  ball  of  0.30  cal.  the  skin  ceases  to 
be  burned,  or  at  which  powder  grains  are  no  longer  em- 
bedded, w'ill  be  less  than  with  one  of  0.32  cal.,  and  with  a 
ball  of  0.25  cal.  the  range  within  which  these  effects  are 
possible  will  be  somewhat  greater  than  with  one  of  0.22 
cal.  The  problem  to  be  solved  is  usually  that  of  the  pos- 
sibility of  suicide  in  cases  in  which  homicide  is  suspected, 
and  as  in  homicide  the  range  is  usually  Avithin  that  in 
which  suicide  is  practicable,  and  Avithin  which  superficial 
effects  are  not  essentially  diff'erent  for  approximate 
calibres,  sufficient  accuracy  will  be  assured. 

The  number  of  instances  in  Avhich  cadaveric  observa- 
tion can  be  made  decisive  in  determining  the  exact  condi- 
tions under  which  wounds  have  been  inflicted  during  life 
is  by  no  means  large,  but  this  restriction  cannot  be  taken 
as  a  measure  of  its  value.  The  absolute  certainty  that 
there  is  no  range  within  which  a  suicidal  bullet  wound 
might  not  have  been  homicidal,  and  that  in  the  vast  ma- 
jority of  cases  no  evidence  afforded  by  necropsy  can  discrim- 
inate the  one  from  the  other,  is  in  its  application  to  indi- 


298  IN'JURIES    OF    THE    BRAIN    AND    MEMBRANES. 

vidual  cases  no  less  important  as  a  negative  conclusion 
than  the  positive  fact  that  in  certain  exceptional  cases  the 
wound  is  necessarily  homicidal.  It  is  only  by  largely 
extended  experimentation  that  the  line  which  separates 
these  two  classes  of  cases  can  be  accurately  defined. 


Cranial  Lesions. 

The  osseous  wounds  of  entrance  and  exit  present 
certain  peculiarities  which  are  invariable,  whatever  may 
be  the  calibre  of  the  ball  which  has  produced  them  or  the 
range  at  which  they  have  been  inflicted.  There  are  in- 
stances, not  infrequent,  in  which  the  cranial  lesions  may 
determine  both  range  and  calibre,  but  in  general  they 
have  few  characteristics  absolutely  indicative  of  either. 
The  characters  which  they  have  in  common  are  an 
osseous  opening  larger  than  the  ball  and  an  unequal  com- 
minution of  the  osseous  tables,  which  has  a  definite  rela- 
tion to  its  direction.  The  wound  of  entrance  is  usually 
not  very  much  larger  than  the  ball,  and  may  thus  abso- 
lutely determine  its  calibre.  The  diameter  of  a  circular 
perforation  of  the  bone  made  by  a  ball  of  0.22  cal.  may  be 
smaller  than  that  of  the  ball  itself  of  any  of  the  larger 
calibres;  and  the  diameter  of  a  similar  perforation  when 
made  by  a  ball  of  0.44  cal.  may  be  larger  than  any  which 
has  been  observed  with  balls  of  smaller  size.  Irregular 
or  even  circular  openings  when  made  by  balls  of  0.32  or 
0.38  cal.  are  individually  indistinguishable  from  each  other, 
as  they  may  be  even  from  those  of  0.22  or  0.44  cal.  The 
direct  osseous  wound  is  u.sually  made  by  a  fine  comminu- 
tion, but  instances  are  observed  in  which  a  circular  piece  is 
punched  out  of  the  bone  and  perhaps  remains  attached  to 


300  INJURIES    OF    THE    BRAIN   AND    MEMBRANES. 

the  dura.  The  wound  of  exit,  in  which  comminution  is 
more  extensive  and  involves  larger  fragments,  can  hardly 
afford  in  any  case  a  clew  to  the  calibre  of  the  ball. 

The  unequal  comminution  of  the  two  tables  is  not  only 
observed  at  all  ranges  and  with  all  calibres,  but  occurs  in 
all  regions  of  the  cranium  where  two  osseous  tables  exist. 
At  the  site  of  entrance  the  edge  of  the  external  table  is 
sharp  and  clean  cut.  while  the  margin  of  the  internal  table, 
to  an  extent  of  }b  "  more  or  less,  is  eroded  by  fine  commi- 
nution. This  erosion  of  the  margin  of  the  inner  table  has 
the  appearance  of  having  been  produced  by  the  gnawing 
of  small  teeth  or  by  the  use  of  a  fine  rongeur,  and  is  very 
characteristic.  At  the  site  of  exit,  when  the  bone  is  not 
too  extensively  comminuted  for  observation,  these  condi- 
tions are  reversed ;  the  margin  of  the  inner  table  is  clean 
cut,  and  that  of  the  external  table  eroded. 

The  exact  diagnostic  value  to  be  attributed  to  other 
circumstances  of  cranial  injury  may  be  best  appreciated 
by  a  study  of  the  results  of  observation  arranged  in  statis- 
tical form. 

I .    Cranial  Poictration. 

(a)  0.44  cal.      Pistol  of  most  eificient  type. 

41  observations. 

40  penetrations — 40  exits. 
I  non-penetration  at  range  of  30  ft., 

with  the  point  of  incidence  just  above  the  supraorbital 
ridge  and  with  one  fragment  of  the  ball  wnthin  the  ex- 
ternal table. 

I  exit  not  cutaneous. 

Ranges,  from  contact  to  too  ft.,  inclusive,  in  frontal, 
temporal,  parietal,  and  occipital  regions. 


* 


302  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

{b)  0.44  cal.      Pistol  of  inferior  type. 
34  observations. 
19  penetrations. 
6  exits,  and 

4  cases  in  which  without  exit  the  bone  was  fractured 
and  the  ball  fell  back  into  the  brain,  at  ranges  of  contact, 
6",  5  ft.,  and  20  ft. 

15  non-penetrations: 

I  at  range  of  i  in.  i  at  range  of  10  ft. 

1  "       "        "  6    "  3 30  " 

2  "       "        "    I  ft.  I   "       "       "    40  " 

I   "       "        "  3   "  I   "       "       "    50  " 

I    "       "        "   5    "  3,  range  not  noted. 

These  involved  all  regions  of  the  cranium. 
The  ranges  at  which  exit  occurred  were : 

At  contact,  i.  At     50  ft.,  i. 

3  in-   I-  "     75  ft.,  I. 


20  ft.,    I.  "    100  ft. 


I 


The  ranges  at  which  penetration  occurred  without  exit 
were  from  contact  to  50  ft.  inclusive. 

{c)  0.38  cal. 
1 14  observations. 
106  penetrations — 75  exits. 

8  non-penetrations. 
Xon-exits: 


o  at  contact  with  10  observ 

2  at  range  of  >^  to  i  in.  with  17  observations. 

,    "       "       "  3    " 

8  "       "       "  6    " 

2   "       "       "  I  ft. 


ations. 


/ 
16 


304 


INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 


2  at  range  of     2  ft.  with    6  observations. 


3  " 

"     "       3   ' 

8 

2   " 

"     "       4  ' 

4 

2   " 

"     "       6  ' 

3 

4  " 

"     "      10  ' 

G 

0  " 

"     "      15   ' 

'        "       2 

0  " 

"     "     20  ' 

'        "        I 

0  " 

"     "     25   ' 

i                i*               ^ 

0  " 

"     "     30  ' 

*                **               1 

3  " 

35 

"       6 

I   " 

"     "     40  ' 

I 

0  " 

u     .     ^Q  . 

I 

I   " 

"     "    100  ' 

Non-penetrations. 
I   at  range  of    2  ft.  in  parietal  region. 


I    " 

u           g 

'    in  occipital       " 

I    " 

"       "   10 

'    upon  temporal  ridge. 

I    " 

"  20 

'    in  fronto-parietal  region. 

2     " 

"     "  40 

'    in  occipital  region. 

I      " 

"  40 

'    in  parietal 

I      " 

"  40 

'    upon  frontal  curve. 

((if)  0.32  cal. 
126  observations. 
115  penetrations — 33  exits. 
1 1  non-penetrations. 

Xon-exits: 

I  at  contact  with  2  observations. 
15  at  range  of    >2   in.  with   19  ob.servations. 


3Q6 


IxMJUKIES    OF    THE    BRAIN    AND    MEMBRANES. 


14  at  range  of     6    in.  with    18  observations. 
1 1 

4 
6 


I   tt. 

17 

2        " 

"       12 

3     " 

6 

3/3" 

"        2 

4     " 

**        0 
.) 

5 

8 

6     " 

7 

10     " 

3 

15      " 

"        2 

20     " 

"             o 

25      " 

5 

A  large  proportion  of  the  exits  were  not  cutaneous. 
Non-penetrations : 

I  at  range  of  3  in.  in  mid-frontal  region. 


6   "     " 
I    ft.  " 


I 

3  ' 

4  ' 

4  ' 

5  ' 

6  ' 


mastoid  region. 

"     inferior  occipital  region. 
tt  tt  tt  tt 

upon  temporal  ridge, 
in  mid-temporal  region. 
"    posterior  parietal  region. 


It  will  be  observed  that  failure  of  penetration  with  this, 

as  with  0.38  cal.  usually  occurred  in  regions  in  which  the 

resistance  offered  by  the  cranial  wall  is  greatest,  or  upon 

curves  which  favor  the  deflection  of  the  ball. 

* 
(r)  0.22  cal. 

163  observations. 


3o8 


INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 


In  a  first  series  of  30  observations  there  were  but  1 1 
penetrations,  and  in  6  of  these  the  dura  mater  was  unin- 
jured. As  all  cartridges  of  0.22  cal.  are  rim  fire  and 
deteriorate  with  age,  it  is  probable  that  those  used  in  this 
instance  were  old  and  in  bad  condition.  In  a  second  series 
comprising  133  observations,  there  were  100  penetrations. 
Both  series  were  at  ranges  from  contact  to  25  feet,  inclu- 
sive, and  involved  the  frontal,  temporal,  and  occipital 
regions,  as  did  the  previous  observations  made  with  other 
calibres.     In  the  second  series  there  were : 

At  a  range  of  contact,    5   penetrations  in   7  observations. 

14 
21 

15 
16 

15 

12 

2 

12 

15 

2 

I 

I 

There  were  no  exits,  and  only  one  instance  in  which 
the  opposite  surface  of  bone  was  fractured. 

The  fact  of  cranial  penetration  or  non -penetration 
depends  not  only  upon  range  and  calibre  but  upon  con- 
comitant circumstances  of  even  greater  importance.  There 
are  pistols  of  inferior  grade  with  which  penetration  is 
always  uncertain  if  not  improbable;  many  of  those  of  0.22 
cal.   are    of  this  character,   and    the    cheaper  varieties    of 


I  m.. 

12 

3   " 

15 

6  " 

14 

I   ft.. 

13 

0   '■ 

1 1 

3  " 

8 

4  " 

2 

6   " 

6 

10  " 

10 

15    " 

2 

20  " 

I 

25    " 

I 

3 TO  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

0.44  cal.  are  scarcely  more  efficient.  In  observations 
made  with  what  is  termed  an  "  American  bulldog"  of  0.44 
cal.  penetration  occurred  in  but  little  more  than  50  per 
cent,  at  all  ranges,  while  in  those  made  with  a  pistol  of 
the  same  calibre  of  the  highest  grade  it  failed  in  but  a 
single  instance.  It  is  necessary  therefore  to  found  such 
conclusions  as  may  seem  justifiable  only  upon  the  results 
attained  in  the  use  of  weapons  of  standard  type.  The 
physical  characters  of  the  crania  assailed,  J>cr  co/itrci,  may 
be  such  as  abnormally  to  increase  their  power  of  resist- 
ance. Their  density  not  less  than  their  comparative 
thickness,  and  the  absence  of  diploic  structure,  often  ren- 
der them  impenetrable  even  to  balls  of  large  size  at  short 
range.  The  impact  of  a  ball  upon  a  cranial  curve,  or  at 
an  angle  of  great  obliquity,  may  determine  its  deflection 
from  the  surface.  These  several  considerations  make  it 
difficult  to  formulate  any  exact  rules  which  may  govern 
penetration  for  balls  of  given  calibres  at  stated  distances. 
In  general,  the  larger  the  calibre  of  the  ball,  other  condi- 
tions being  the  same,  the  greater  the  probability  of  pene- 
tration. The  truth  of  this  proposition  is  evident  from  the 
present  series  of  tabulated  results.  The  influence  of  range 
can  be  less  positively  stated.  It  is  probable  that  with  any 
pistol,  except  it  be  one  of  0.22  cal.,  penetration  rarely 
fails  at  contact;  that  with  a  pistol  of  0.44  cal.,  of  the 
better  type,  it  always  occurs  at  a  range  of  one  foot  or  less, 
except  in  rare  instances  in  which  cranial  peculiarities  or 
the  angle  of  incidence  afford  obvious  explanation ;  and 
that  with  a  pistol  of  0.32  calibre  it  is  practically  certain ; 
but  the  conditions  are  too  complicated  for  mathematical 
expression.  The  ball  has  invariably  made  exit  at  all  ranges 
when  of  the  best  type  of  0.44  cal.,  and  never  at  any  range 


312  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

when  of  0.22  cal.  Exit,  like  penetration,  with  balls  of  0.32 
or  0.38  cal.,  is  influenced  by  accidental  conditions  and 
made  to  some  extent  uncertain.  The  average  number  of 
exits  with  balls  of  0.38  cal.  is  70  per  cent,  or  more,  and 
with  those  of  0.32  cal.  less  than  35  per  cent. 

2.    The  Dimensions  of  Cranial  Wounds. 

Measurements  were  made  of  the  cranial  wounds  of  en- 
trance and  exit  in  308  observations. 

The  wound  of  entrance  was  apparently  unaffected  in 
size  or  form  by  length  of  range.     It  was  circular  in  123. 

0.44  cal. — 45  observations. 
Range,  from  contact  to  100  feet: 
In    14  obs.,   diam.    \    in.     In    i   obs.,   diam.    V^   in- 

4  T6  I  n 

"  I  "  "  5/^       "  -        I  "  "I       " 

Total,  22. 

In  the  23  observations  remaining,  the  diameters  varied 
from  r  XiV'toi"  Xi^". 

0.38  cal. — 75  observations. 

Range,  from  contact  to  100  feet: 

In  18  obs.,  diam.  a^  in.     In  2  obs.,  diam.   %  in. 
"    4     "  "        i    "         "    3       "  "        T^  to  I  in. 

Total,  2-]. 

In  the  48  observations  remaining,  the  diameters  varied 
from  i)i"  y.  >^"  to  i3^"x  y%". 


314  IN'JURIES    OF    THE    BRAIN    AND    MEMBRANES. 

0.32  cal. — 96  observations. 
Range,  from  contact  to  30  feet : 
In    16  obs.,   diam.  3^  in.      In    i   obs.,   diam.    i    in. 


5      "  "         i    "         "    3      ''  "       ^ 

4      "  "        %   "         "    3      " 


— 5_    " 
1  6 

7       " 
T6 


"         I         "  "  ^     "  "      I         " 

Total,  34. 

In  the  62  observations  remaining,  the  diameter  varied 
from  si"  X  V  ^o  Ys"  X   %". 

0.22  calibre — 92  observations. 
Range,  from  contact  to  20  feet: 
In  24  obs.,   diam.    i    in.      In   7  obs.,   diam.    ->8   in. 

a         _         (<  u  5       <(  u       T        "  "7         " 

3  T¥  *  T6" 

"      3      "  "        T%    "  Total.  40. 


In  the  52  observations  remaining,  tlie  diameter  varied 
from  i"  X  3//"  to  Y  X   Yq" . 

The  number  of  wounds  of  entrance  which  are  circular 
is  thus  much  more  than  one-third  of  all  those  subjected  to 
measurement;  those  of  the  remainder  which  are  nearly  so 
add  materially  to  the  percentage  and  do  not  affect  the 
average  of  diameters.  These  circular  wounds  may  be 
proper!}'  regarded  as  characteristic  of  the  several  calibres, 
while  those  of  irregular  form  indicate  secondary  com- 
minution. In  the  case  of  balls  of  0.44  cal.  the  diameter 
of  more  than  '75  per  cent,  of  circular  osseous  wounds  of 
entrance  is  i",  or  a  trifle  less;  in  the  case  of  those  of 
0.38  cal.  it  is  }i"  in  66  per  cent.;  in  the  case  of  those 
of  0.32   cal.  it  is  also  4^"  in   nearly   50  per  cent.;  and  in 


3i6 


INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 


the  case  of  balls  of  0.22  cal.  it  is  y,  or  a  trifle  more, 
in  nearly  75  per  cent.  The  osseous  wounds  when  cir- 
cular are  the  result  of  a  fine  comminution  of  bone  by 
the  ball  in  its  progress — so  line  that  no  part,  or  an  incon- 
siderable part  of  it,  may  be  detected  in  the  intracranial 
cavity.  Even  if  the  wound  is  more  than  double  the 
diameter  of  the  bullet,  no  osseous  particle  of  appreci- 
able size  may  exist  either  within  or  without  the  cranial 
opening.  In  occasional  instances,  in  place  of  this  species 
of  disintegration,  a  single  circular  fragment  may  be 
punched  out  and  remain  attached  to  the  dura  mater.  It 
is  not  impossible  that  in  every  case  the  bone  may  be  suffi- 
ciently compressible  to  permit  some  further  enlargement 
of  the  wound. 

The  size  of  cranial  wounds  of  exit  is  difficult  to  de- 
scribe, as  they  are  irregular  in  outline  and  as  there  is  no 
means  of  discriminating,  what  may  be  termed  direct  from 
attendant  or  complicating  comminution.  The  only  prac- 
ticable method  of  limitation  seems  to  be  to  regard  only 
those  fragments  as  constituting  a  part  of  the  wound  which 
are  of  small  size  and  in  immediate  relation  with  the  course 
of  the  ball. 

In  the  308  observations  there  are  43  exits,  of  which  the 
longest  diameters  are  tabulated : 


a.   0.44. 

cal. 

In 

I 

obs.. 

diam. 

2     in. 

X 

I 

2       " 

X 

3 

2       " 

X 

I 

iy2 " 

X 

I 

^y " 

X 

4 

'><" 

X 

m, 


i^  " 


3i8 


INJURIES    OF   THE    BRAIN    AND    MEMBRANES, 


In     3     obs.,    diam.       i 


m. 


X 
X 


J      m. 

3/     " 


Total,  17. 


/; 

0.38 

cal. 

In 

I 

obs., 

d 

iam. 

2      in. 

X 

ly  ir 

(( 

I 

It 

tt 

134  " 

X 

-^" 

u 

I 
I 

(( 

It 

i>^" 
15^  " 

X 
X 

^y- 

" 

I 

t< 

" 

ly^  " 

X 

I     " 

" 

5 

«t 

n 

i>^" 

X 

I     " 

It 

2 

ti 

♦' 

i>^ " 

X 

I^ " 

<( 

I 

It 

a 

i/^  " 

X 

3/" 

" 

I 

" 

n 

ly,- 

X 

I     " 

(< 

I 
I 

a 

tt 

ly  " 
I 

X 
X 

I     " 

I    " 

Total,  16. 

c. 

0.32 

cal. 

In 

I 

obs., 

diam. 

2      in. 

X 

H  in 

u 

1 

" 

i>^  " 

X 

^y^ 

n 

2 

11 

i>^   " 

X 

I       '• 

a 

I 

ti 

ly  " 

X 

y 

<< 

2 

ii 

15^" 

X 

1 

(( 

I 

ti 

I 

X 

I       " 

<< 

2 

" 

I 

X 

y " 

Total,  10. 

d.  0.22  cal. 

No  exits  occur;  in  only  a  single  instance  the  bone  was 
fissured  by  the  impact  of  the  ball  at  a  point  opposite  its 
entrance. 


MEDICO-LEGAL   RELATIONS.  319 

The  size  of  the  osseous  wound  of  exit  is  not  materially 
influenced  by  the  length  of  range,  and  while  its  average 


Pig.  38.— OU4  Cal.    Range,  6".     Osseous  Wound  of  Entrance  through  External  Table 

is  somewhat  increased  with  the  calibre,  the  differences  are 
insufficient  to  be  of  value  in  the  determination  of  doubtful 
cases. 


320  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

3.    Cranial  Coinniinutioti  and  Fissuring. 

Comminution  or  fissuring  of  the  skull  may  occur  either 
at  entrance  or  at  exit,  or  at  both  points  at  once.  The  com- 
minution of  the  wound  of  entrance  usually  consists,  where 
the  bone  is  thin,  as  in  the  temporal  fossa  or  squamous 
region,  in  a  limited  and  unimportant  breaking  down  of 
the  immediately  contiguous  part;  and  where  the  bone  is 
thicker  in  a  slight  scaling  of  the  external  table.  The  de- 
struction of  bone  at  the  exit  is  likely  to  be  much  more 
considerable.  The  fissures  which  are  produced  may  be 
quite  as  extensive  when  beginning  at  the  point  of  entrance 
as  at  the  point  of  exit.  The  minute  fissures  which  may 
radiate  for  a  little  distance  from  either  wound,  of  scarcely 
more  than  capillary  size,  are  not  reckoned  in  the  tabula- 
tion. 

0.44  cal. 
Range,  from  contact  to  i " : 

Entrance,  8  observations,  5  fissured. 

Exit,  7  "  3        "         3  comminuted. 

Range,  from  3"  to  6" : 

Entrance,  5  observations,  i  fissured,  2  comminuted. 
Exit,  5  "  I         "  I 

Range,  from  i  foot  to  6  feet: 

Entrance,  9  observations,  5  fissured. 

Exit,  7  "  5         "  I  comminuted. 

Range,  10  feet: 

Entrance,  2  observations,   2  fissured. 
Exit,  2  "  I        " 


322  INJURIES   OF   THE    BRAIN    AND    MEMBRANES. 

Range,   from  15  feet  to  30  feet: 

Entrance,  8  observations,  7  fissured. 

Exit,  6  observations,  2  fissured,  2  fiss'd  and  com'd. 

Range,  40  feet: 

Entrance,  i  observation,  no  fissure  or  comminution. 
Exit,  same  observation,  fissured. 

Range,  from  50  feet  to  100  feet: 

Entrance,  3  observations.  2  fissured.  3  comminuted. 
Exit,  3  "  1         "  2  " 

0.38  cal. 

Range,  from  contact  to  i": 

Entrance,  17  observations,  4  fissured,  4  comminuted. 
Exit,  14  "  4        " 

Range,  from  3"  to  6": 

Entrance,  14  observations,  6  fissured,  1  comminuted. 
Exit,  10  obs.,  2  com'd,  i  fiss'd  and  com'd. 

Range,  from  i  foot  to  6  feet : 

Entrance,  19  observations,   12  fissured. 

Exit,  12  "  4        "        3  comminuted. 

Range,  10  feet: 

Entrance,     4  observations,  3  fissured. 
Exit,  10  "  1 

Range,  from  15  feet  to  30  feet: 

Entrance,  5  observations,  4  fissured,  i  comminuted. 
Exit,  4  observations,  i  fissured,  i   fiss'd  and  com'd. 


324  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

Range,  40  feet : 

Entrance,  i  observation,  i  fissured. 
Exit,  same  observation,  fissured. 

Range,  from  50  feet  to  100  feet: 

Entrance,  4  obs.,  i  fiss'd,  i  fiss'd  and  com'd. 

Exit,  2      "    (at  50  ft.  and  100  ft.),  both  com'd. 

0.32  cal. 
Range,  from  contact  to  1": 

Entrance,  22  observations,  5  fissured,  4  comminuted. 
Exit,  5  "  I         "         I 

Range,  from  3"  to  6": 

Entrance,  18  observations,  4  fissured,  3  comminuted. 
Exit,  9  "  4        "         I 

Range,  from  i  foot  to  6  feet: 

Entrance,  43  observations,  10  fissured,  8  com'd. 
Exit,  18  "  2>         ''  7       '' 

Range,  10  feet: 

Entrance,  5  observations,  o  fissured,  2  comminuted. 
Exit,  3  "  2         "         o  " 

Range,  from  15  feet  to  20  feet: 

Entrance,  8  observations,  4  fissured,  i  comminuted. 
Exit,  3  "  2         "         o  " 

Range,  from  25  feet  to  30  feet: 

Entrance,  5  observations,  1  fissured,  2  comminuted. 
Exit,  2  "  2        " 

0.22  cal. 
Range,  from  contact  to  i": 

Entrance,  14  observations,  3  comminuted. 


^ 


326  INJURIES   OF   THE    BRAIN    AND    MEMBRANES. 

Range,  from  3"  to  6": 

Entrance,  25  observations,  no  fissure,  no  com'n. 

Range,  from  i  foot  to  6  feet: 

Entrance,  42  observations,  10  comminuted. 

Range,  from  9  feet  to  10  feet. 

Entrance,  8  observations,  3  comminuted. 

Range,  from  15  feet  to  20  feet. 

Entrance,  12  observations,  no  fissure,  no  com'n. 

In  wounds  of  entrance  made  by  balls  of  0.22  cal.  it 
will  be  noted  that  there  is  no  fissuring  of  the  bone,  and 
that  comminution  is  absolutely  or  relatively  small.  In 
case  of  other  calibres  of  ball,  fissuring  is  only  exception- 
ally extensive  at  either  entrance  or  exit,  and  unless  at 
contact  is  governed  rather  by  the  physical  properties  of 
the  crania  than  by  range. 

The  amount  of  positive  information  to  be  derived  from 
the  observation  of  cranial  lesions  is  limited,  but  may  be 
important,  both  intrinsically  and  as  confirmatory  of  that 
afforded  by  the  changes  wrought  in  the  superficial  struc- 
tures. The  further  inferences  which  they  may  warrant, 
though  not  authoritative  in  elucidating  the  history  of 
doubtful  cases,  may  so  materially  strengthen  probabilities 
already  established  by  external  examination  as  to  give  to 
them  the  semblance  of  certainty. 

Intracranial  Lesions. 

In  the  investigation  of  the  conditions  under  which  pis- 
tol-shot wounds  involving  the  cranial  cavity  have  been 
produced,  cadaveric  observation    is    of   only  confirmatory 


MEDICO-LEGAL    RELATIONS.  327 

value.  It  is  impossible  to  determine  how  far  post-mortem 
changes  in  the  brain  structure  or  in  its  membranes  may 
modify  the  characters  of  injuries  experimentally  produced, 
and  this  uncertainty  is  sufficient  to  vitiate  any  conclusions 
they  might  otherwise  suggest.  The  cadaveric  changes  in 
the  brain  are  undoubtedly  rapidly  destructive  and  attended 
by  marked  alteration  in  its  physical  properties.  Its  power 
of  resistance  is  lessened  by  a  process  of  softening  and  dis- 
integration, and  at  the  same  time  the  elasticity  of  its 
fibrous  covering  is  probably  lost,  as  it  is  known  to  be 
in  other  dead  tissues  of  similar  character.  The  first  prop- 
osition may  be  assumed  from  common  observation,  and  the 
second  is  illustrated  by  the  course  of  balls  of  0.22  cal., 
which  in  the  living  subject  so  often  penetrate  the  cranium 
and  traverse  a  considerable  distance  beween  it  and  the  un- 
injured dura  mater,  and  in  the  cadaver,  having  penetrated 
the  bone,  rarely  fail  to  enter  the  brain.  The  course  of  the 
ball  through  the  living  structures,  therefore,  cannot  be  in- 
ferred with  even  reasonable  certainty  from  post-mortem 
experimentation  under  analogous  conditions.  Fortunately 
it  is  practicable  to  determine  the  characteristics  of  intra- 
cranial pistol-shot  lesions  from  their  necropsic  inspection 
when  inflicted  during  life,  since  the  possibility  of  acci- 
dental disturbance  or  alteration  %Yhich  attaches  to  the  pe- 
culiarities of  the  external  wound  is  averted  in  consequence 
of  their  inaccessible  situation.  The  number  of  recorded 
instances  in  w^hich  attention  has  been  directed  to  this 
class  of  intracranial  lesions  is  not  large,  and  these 
have  been  in  great  part  scattered  through  the  history 
of  criminal  proceedings.  The  records  of  the  coroner's 
office  in  New  York,  which  ought  to  afford  a  vast  amount 
of    surgical    information    of     this    nature,   register    only 


328  INJURIES    OF    THE    BRAIN    AND    MEMBRANES, 

the    simple  fact  of    death  from   pistol-shot  wound  of  the 
head. 

The  present  collection  of  cases  of  intracranial  injury 
includes  forty  of  pistol-shot  origin,  which  is  perhaps  an 
adequate  number  for  the  purpose  of  medico-legal,  if  not  of 
clinical  conclusions. 

The  three  points  which  it  may  be  of  medico-legal  im- 
portance to  determine  in  case  of  pistol-shot  wounds  are 
the  calibre,  range,  and  direction  of  the  ball. 

The  calibre  of  a  ball  inaccessibly  located  in  the  cranial 
cavity  during  life,  or  lost  upon  exit  whether  before  or 
after  death,  must  in  general  be  inferred  or  demonstrated, 
if  at  all,  from  conditions  of  the  external  and  osseous 
wounds-  which  have  been  already  indicated.  The  lacera- 
tion of  the  brain  substance  produced  by  the  passage  of  the 
ball  presents  no  differences  in  character  or  extent  which 
serve  to  measure  its  size  with  any  useful  degree  of  pre- 
cision. In  general,  the  larger  the  ball  the  wider  the  area 
of  laceration  which  attends  its  course,  but  as  it  may  be 
driven  forward  either  with  or  without  change  in  its  axis^ 
its  track  may  approximate  in  width  either  its  transverse  or 
its  longitudinal  diameter  and  the  value  of  this  distinction 
be  lost.  In  a  minority  of  cases  in  which  the  ball  is  excep- 
tionally large  or  small,  the  greater  or  lesser  extent  of  lac- 
eration may  be  sufficient  in  itself  to  determine  positively 
the  question  of  calibre.  The  cerebral  track  of  a  ball  of 
0.22  cal.  may  be,  and  usually  is,  too  minute  to  have  been 
conceivably  made  by  one  of  any  larger  size;  the  corre- 
.  spending  track  of  a  ball  of  0.44  cal.  may  be  too  wide  to 
have  been  possibly  made  by  one  of  0.22  cal.,  and,  range 
and  attendant  conditions  of  the  cranial  and  external 
wounds  taken  into  consideration,  too  wide  to  have  been 


MEDICO-LEGAL    RELATIONS.  329 

probably  made  by  one  of  intermediate  size ;  but  with  balls 
of  0.32  or  0.38  cal.,  in  regard  to  which,  by  reason  of  more 
general  and  almost  equally  frequent  usage  the  distinction 
becomes  most  important,  it  is  impossible  to  make.   • 

.  The  absolute  extent  of  brain  laceration  greatly  varies. 
The  wound  made  by  a  ball  of  0.22  cal.  may  be  of  such  te- 
nuity that  it  is  difficult  to  trace  beyond  the  beginning  of 
its  course,  and  in  necropsic  examinations  it  may  become 
necessary  to  abandon  the  effort  and  to  locate  the  position 
of  the  ball  except  by  minute  dissection  of  the  entire  organ. 
If  the  ball  has  been  one  of  larger  calibre,  the  area  of 
laceration  is  from  33"  to  i"  in  diameter,  the  brain  tissue 
is  disintegrated  and  mingled  with  minute  coagula,  or  the 
cavity  which  has  been  formed  is  more  rarely  filled  with  a 
single  coagulum  through  its  whole  extent.  Its  width  can 
be  most  accurately  appreciated  by  incising'  the  brain  at 
right  angles  to  the  plane  of  its  general  direction.  If  in- 
cision be  made  through  its  long  axis,  a  gaping  wound  is 
displayed  of  deceptive  size,  which  becomes  larger  with 
every  •  disturbance  of  the  parts.  Along  its  margin  the 
punctate  extravasations  and  local  discoloration  of  the  lim- 
ited form  of  contusion  may  be  often  noted.  The  concomi- 
tant lesions,  the  general  oedema  and  hypersemia  of  general 
contusion  which  is  characteristic,  and  the  several  forms  of 
hemorrhage  which  are  accidental  have  no  significance  in 
this  relation,  and  no  inferences  can  be  derived  from  the 
depth  to  which  the  ball  may  penetrate. 

The  range  or  the  distance  traversed  by  the  ball  from  the 
point  of  discharge  from  the  weapon  to  the  point  of  impact 
cannot  be  estimated  even  approximately  from  an  examina- 
tion of  the  cranial  contents.  One  or  two  exceptions  may 
be  made  to  this  general  statement.     At  contact,  or  within 


330  INJURIES   OF   THE    BRAIN    AND    MEMBRANES. 

a  range  which  approximates  it,  the  dura  may  be  torn  or 
destroyed,  and  the  contiguous  brain  substance  irregularly 
lacerated  to  an  extent  which  is  not  observed  at  greater  dis- 
tances. It  has  been  stated  in  a  previous  section  that  in 
wounds  inflicted  upon  the  cadaver,  at  ranges  of  six  inches 
or  less,  grains  of  powder  may  be  detected  upon  the  con- 
tiguous surfaces  of  the  cranium  and  dura  or  in  the  course 
of  the  cerebral  laceration ;  but  it  has  been  also  noted  that 
in  wounds  inflicted  during  life  hemorrhage  is  sufficient  to 
make  the  appreciation  of  this  indication  improbable.  Aside 
from  these  exceptional  instances,  in  which  external  appear- 
ances are  corroborated  by  some  circumstance  of  internal 
injury,  there  are  no  conditions  of  the  intracranial  wound 
which  help  to  establish  even  a  probability  in  estimating 
length  of  range.  At  all  distances,  from  contact  to  limit  of 
observation,  the  ball  may  traverse  the  whole  extent  of  the 
brain  in  any  of  its  diameters.  The  thickness  or  density 
of  the  skull,  the  point  of  impact,  or  the  angle  of  incidence 
are  much  more  influential  than  range  in  determining  not 
only  the  depth  of  penetration  but  also  the  amount  and 
character  of  laceration. 

The  direction  in  which  the  ball  has  been  projected  is 
readily  determined  in  those  cases  in  w-hich  after  penetrating 
the  cranium  it  has  overcome  the  elasticity  of  the  dura  and 
entered  the  brain.  The  resistance  offered  by  the  bone 
does  not  deflect  it  from  its  course,  and  the  passing  of  a 
probe  through  the  superficial  and  cranial  wounds  into  the 
beginning  of  the  cerebral  track  establishes  a  line  which  in 
its  continuation  is  the  one  which  the  ball  has  traversed. 
If  the  bone  has  not  been  penetrated,  or  the  dura  has  re- 
mained uninjured,  it  is  impossible  to  ascertain  with 
either  certainty  or  precision  the  course  the  ball  has  taken. 


MEDICO-LEGAL    RELATIONS.  33  I 

At  ranges  short  enough  to  afford  marks  of  smoke,  fiame, 
or  powder  upon  the  surface,  their  limitation  in  some  in- 
stances to  a  single  aspect  of  the  wound  may  indicate  in  a 
general  way,  as  may  subcutaneous  fragments  of  lead  car- 
ried beyond  the  osseous  entrance,  the  side  from  which 
the  ball  has  been  discharged.  At  longer  ranges  no  infer- 
ences as  to  direction  can  be  made  unless  a  cerebral  track 
exists. 

The  general  study  of  pistol-shot  wounds  of  the  head,  by 
means  of  extended  experimentation  upon  the  cadaver,  has 
afforded  a  definite  amount  of  positive  information.  It  has 
been  equally  fruitful  of  negative  results  of  no  less  positive 
value.  The  certainty  that  a  questionable  medico-legal 
fact  cannot  be  determined  by  the  presence  or  absence  of 
given  post-mortem  conditions  may  be  quite  as  important 
as  the  demonstrably  necessary  dependence  of  the  same 
conditions  upon  some  other  circumstance  of  injury.  It 
may  be  of  even  greater  importance  to  recognize  fully  the 
impossibility  of  solving  a  question  of  suicide  or  homicide 
than  to  be  able  positively  to  infer  the  calibre  of  the  ball  or 
its  approximate  range.  The  uncertainty  which,  in  the 
absence  of  previous  investigation,  has  existed  as  to  just 
how  far  the  circumstances  under  which  a  wound  has  been 
inflicted  can  be  legitimately  inferred  from  post-mortem 
phenomena,  has  led  to  the  expression  of  dogmatic  opin- 
ions which  have  been  altogether  unwarranted.  Conclu- 
sions, largely  theoretical,  and  more  or  less  based  upon  un- 
due generalizations  from  scanty  observation,  and  exploited 
as  demonstrated  facts,  are  not  rare  in  the  records  of  crim- 
inal procedure.  The  preceding  observations  will  be  of 
use,  therefore,  not  only  as  they  indicate  just  what  post- 
mortem appearances  can  fix  calibre,  range,  or  direction, 


332  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

with  that  absolute  certainty  necessary  to  criminal  investi- 
gation, but  also  as  they  serve  to  fix  the  limit  at  which 
knowledge  ends  and  conjecture  begins.  The  practical 
combination  of  positive  and  negative  indications  for  the 
interpretation  of  particular  cases,  the  reconciliation  of  ap- 
parent discrepancies  in  certain  instances,  the  utilization  of 
the  material  collected,  properly  concerns  the  formal  writer 
upon  medical  jurisprudence.  It  is  the  present  purpose  to 
aggregate,  compare,  and  generalize  the  facts  noted,  rather 
than  to  direct  their  application. 

The  total  number  of  observations  made  upon  the  cada- 
ver in  this  study  of  pistol-shot  wounds  of  the  head  is 
slightly  in  excess  of  one  thousand,  exclusive  of  those 
made  upon  the  body  and  extremities.  Many  of  these  in- 
dividually included  an  examination  of  all  the  extracranial, 
cranial,  and  intracranial  lesions;  others  were  limited  to 
such  larger  or  smaller  proportion  of  their  number  as  cir- 
cumstances might  permit;  and  some  did  not  extend  beyond 
the  observation  of  an  isolated  fact.  A  single  head  could 
sometimes  be  utilized  for  a  number  of  shots  if  the  ball  was 
of  small  calibre  or  if  the  range  was  long,  or  it  might  be 
serviceable  for  not  more  than  a  single  one  if  the  calibre 
was  large  and  the  destructive  effects  were  great. 

The  illustrations  which  accompany  the  text  are  of  life 
size  and  are  from  photographs  taken  immediately  after  the 
wounds  were  inflicted.  They  are,  therefore,  exact  repro- 
ductions of  what  was  observed  in  these  specified  instances. 
Those  of  them  which  concern  the  external  parts  are  con- 
fined to  short  ranges,  since  at  greater  distances  there  are 
no  other  superficial  lesions  than  the  cutaneous  opening, 
which  is  not  characteristic.  The  osseous  wounds  which 
are  represented  were  selected  nearly  at  random  from  those 


MEDICO-LEGAL    RELATIONS.  333 

in  calvaria  collected  from  this  series  of  observations  and 
now  in  the  Wood  Museum  of  Bellevue  Hospital,  and  are 
intended  to  show  the  characters  of  such  injuries  in  both 
the  external  and  internal  tables,  at  entrance  and  exit,  in- 
dependent of  range  or  calibre. 


Chapter   VIII. 

SURGICAL   RELATIONS. 

SYMPTOMATOLOGY, 

The  surgical  history  of  pistol-shot  wounds  of  the  head 
is  largely  included  in  that  of  the  general  class  of  intra- 
cranial injuries  to  which  they  belong.  It  involves  the 
same  lesions:  fractures  of  the  cranial  base  and  vault,  gen- 
eral contusions  and  lacerations  of  the  brain,  and  epidural, 
meningeal,  and  cortical  hemorrhages,  which  are  peculiar 
only  in  the  fact  that  they  are  always  direct,  and  never  the 
result  of  indirect  violence.  It  presents  essentially  the 
same  symptoms,  general  and  localizing,  which  are  pro- 
duced by  other  traumatisms  affecting  the  same  parts.  Its 
questions  of  diagnosis,  prognosis,  and  treatment  are  to  be 
solved  in  accordance  with  the  significance  of  symptoms 
upon  lines  already  established,  and  differ  only  as  they  are 
modified  by  the  lodgement  of  a  foreign  body  in  a  perhaps 
unknown  and  inaccessible  part  of  the  brain  or  cranial 
cavity.  It  is  sufficient  therefore  in  the  special  considera- 
tion of  this  form  of  intracranial  traumatism  to  regard 
simply  such  points  of  difference  as  may  obtain  in  conse- 
quence of  the  introduction  of  this  additional  element  in 
the  case.  * 

The  number  of  such  wounds   included  in  the  present 


SURGICAL    RELATIONS.  335 

series  of  intracranial  injuries  is  limited,  and  in  but  few  in- 
stances has  life  been  sufficiently  prolonged  to  necessitate 
raising  a  question  of  either  localization  or  treatment. 
From  1879  to  1S95  inclusive  there  have  been  recorded  in 
more  or  less  detail  in  the  British,  Colonial,  and  American 
journals  and  transactions  of  societies,  one  hundred  and 
forty-five  cases  in  which  patients  have  survived  the  pri- 
mary shock  of  pistol-shot  injury  involving  the  cranial  cav- 
ity, of  which  one  hundred  and  ten  have  been  accessible 
for  comparison.  The  aggregate  number  of  these  pub- 
lished cases,  with  the  addition  of  those  in  the  appended 
series  in  which  death  was  not  immediate  or  was  not  too 
early  to  permit  the  notation  of  symptoms,  or  the  consider- 
ation of  prognosis  or  treatment,  is  one  hundred  and  thirty- 
six,  and  it  is  believed  affords  a  sufficient  basis  for  general- 
ization and  to  warrant  the  conclusions  formulated  in  the 
present  study  of  the  subject.  The  tabulated  collections  of 
pistol-shot  or  other  gunshot  intracranial  wounds  which 
have  been  previously  made  in  skeleton  form  for  statistical 
purposes  are  so  wanting  in  essential  elements  of  compari- 
son as  to  be  practically  valueless  for  the  solution  of  prob- 
lems in  diagnosis  or  treatment. 

Pistol-shot  wounds  of  the  head,  unlike  those  produced 
by  arms  of  longer  range  or  greater  power,  rarely  occasion 
serious  injuries  without  having  penetrated  the  cranium. 
Fragments  of  shell,  spent  rifle  balls,  and  various  missiles, 
by  which  gunshot  wounds  are  otherwise  inflicted,  may 
fracture  the  cranium  or  lacerate  the  brain  without  so  much 
even  as  breaking  the  skin :  the  lesions  are  then  not  differ- 
ent from  those  occasioned  by  other  means  of  violence,  and 
their  svmptoms  and  termination  are  in  no  wise  peculiar. 
A  pistol  ball,  on  the  contrary,  never  causes  a  simple  frac- 


S3^  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

ture,  and  rarely  a  compound  fracture  which  is  more  than 
nominal,  unless  the  bone  is  also  penetrated.  If  the  ball  is 
of  0.2  2  cal.  it  may  even  penetrate  to  the  dura  without 
cerebral  lesion;  if  it  is  of  a  larger  calibre,  there  is  no 
reason  to  believe  that  its  simple  impact  upon  the  bone  has 
ever  been  attended  by  intracranial  complications. 

In  only  exceptional  instances  a  compound  fracture 
without  penetration  has  entailed  consequences  of  a  serious 
character.  In  a  case  reported  by  Mr.  Butcher,  remarkable 
in  various  particulars,  a  compound  depressed  fracture  of 
the  frontal  bone  and  a  subsequent  osteogenic  process,  oc- 
casioned by  the  discharge  of  a  pistol  loaded  only  with 
powder  and  hard  wadding,  produced  epilepsy  and  absolute 
imbecility  through  a  circulatory  disturbance.  The  same 
effects  might  legitimately  follow  in  any  case  in  which  a 
bullet  had  penetrated  only  the  outer  table  and  depressed 
the  inner  one,  if  remedial  treatment  were  not  employed. 
It  is  always  possible  also  that  a  non-penetrating  compound 
fracture,  even  though  a  simple  fissure,  in  the  absence  of 
aseptic  precautions  whether  from  neglect  or  from  an  inac- 
cessibility of  position,  should  afford  a  channel  for  intra- 
cranial septic  infection.  This  accident  will  hardly  occur 
in  fractures  of  the  cranial  vault,  but  is  not  unknown  at  the 
base  in  regions  where  the  bone  is  thicker  and  its  vascular 
spaces  are  larger,  or  where  the  peculiarity  of  its  situation 
prevents  discovery  or  effective  approach.  There  is  a  re- 
corded instance  of  such  an  intracranial  infection  from 
pistol-shot  wound,  in  which  a  suppurative  arachnitis  re- 
sulted from  the  lodgment  of  a  bullet  in  the  petrous  por- 
tion. There  is  a  similar  case  in  which  two  rifle  balls  were 
embedded  in  the  basilar  process  and  led  to  gangrene  of  the 
dura  mater,  epidural  abscess,  and  suppurative  meningitis. 


SURGICAL   RELATIONS.  337 

It  may  be  fairly  stated  that  in  a  pistol-shot  wound  confined 
to  the  soft  parts  and  cranial  vault  this  complication  can 
occur  only  through  a  neglect  of  the  most  ordinary  aseptic 
care. 

If  the  bullet,  of  whatsoever  calibre  it  may  be,  pene- 
trates the  brain,  the  lesions  it  causes  are  still  contusion, 
laceration,  and  hemorrhage,  and  the  general  symptoms 
are  still  those  which  pertain  to  such  conditions,  however 
they  may  have  been  induced. 

The  characteristic  initial  symptom  of  this  variety  of 
intracranial  injury  is  in  the  serious  cases  likely  to  be  espe- 
cially prominent.  The  unconsciousness,  which  is  never 
absent  in  those  which  are  immediately  fatal,  is  of  a  re- 
markable profundity.  It  is  in  part  explicable  by  the  gen- 
eral contusion  which  is  a  factor  in  the  production  of  pri- 
mary unconsciousness  in  all  cerebral  lacerations,  and  is 
continued  and  deepened  by  the  often  profuse  immediate 
cortical  hemorrhage.  An  additional  cause  of  this  condi- 
tion, and  a  possible  explanation  of  its  depth,  may  be  found 
in  a  cerebral  shock  due  to  the  directness  and  magnitude  of 
the  destruction  of  the  nerve  centres.  This  is  apart  from 
material  change  or  the  intervention  of  the  sympathetic  or 
spinal  ganglia,  and  is  rather  akin  to  the  effect  of  emotional 
shock  as  exemplified  in  the  sudden  and  entire  abolition  of 
consciousness  from  an  extremity  of  grief  or  horror.  This 
distinction  is  in  a  measure  recognized  by  Dana,  who,  hav- 
ing defined  shock  as  a  "sudden  depression  of  the  vital 
functions  due  to  nervous  exhaustion  following  an  injury 
or  a  sudden  violent  emotion,"  divides  it  accordingly  into 
"corporeal"  and /'psychic."  In  this  instance  the  injury  is 
corporeal,  but  it  is  inflicted  directly  upon  the  cerebral 
ganglia,  and  its  effect  is  manifested  without  the  impulse 


338  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

having  been  transmitted  to  the  sympathetic  system,  the 
irritation  of  which,  as  shown  by  Boise,  is  the  immediate 
cause  of  the  contracted  arterioles,  pallid  skin,  and  rapid 
pulse  which  characterize  the  shock  of  bodily  injury.  If 
the  profound  unconsciousness  is  to  be  ascribed  solely  to 
the  general  cerebral  contusion,  or,  as  that  lesion  is  inter- 
preted by  Von  Bergmann,  to  the  suspension  of  general 
cortical  activity  from  circulatory  disturbance,  it  presup- 
poses a  greater  derangement  of  cortical  circulation  than 
results  from  other  forms  of  violence  or  is  indicated  by 
necropsic  examination.  In  this  state  of  unconsciousness, 
death  may  ensue  almost  if  not  quite  instantaneously,  or 
after  an  interval  of  hours  or  even  minutes.  Aside  from 
an  abundant  hemorrhage  which  issues  from  the  external 
wound  and  is  of  frequent  occurrence,  and  the  changes 
in  pulse,  temperature,  and  respiration,  this  is  the  entire 
clinical  history  of  a  large  majority  of  cases.  If  the  pulse 
is  primarily  diminished  in  frequency,  the  change  in  this 
direction  is  so  transitory  that  it  is  a  necessarily  inappre- 
ciable symptom. 

In  those  cases  in  which  consciousness  has  not  been  in- 
stantaneously abolished,  it  is  not  often  possible  to  ascertain 
the  immediate  subjective  symptoms.  Suicidal  subjects 
are  indisposed  to  speak  of  the  circumstances  which  at- 
tended the  infliction  of  their  injury,  and  in  many  in- 
stances acute  mania,  alcoholism,  or  innate  stupidity  has 
prevented  its  appreciation,  but  it  has  been  occasionally 
chronicled.  In  the  case  of  a  man  who  shot  himself  in  the 
vertex  and  lacerated  the  longitudinal  sinus  without  impli- 
cating the  brain,  it  was  described  by  him  as  a  sensation 
like  an  electric  shock  followed  by  paraplegia  and  a  brief 
period  of  unconsciousness.     A  woman  who  shot  herself  in 


SURGICAL   RELATIONS.  339 

the  mastoid  process  without  penetrating  the  cranial  cavity 
experienced  excruciating  pain.  A  youth  whose  right 
frontal  lobe  had  been  traversed  by  a  bullet  found  his  imme- 
diate sensations  to  be  those  of  pain  in  the  ear  and  vertigo. 
Another  man,  in  whose  right  frontal  lobe  the  bullet  was 
deeply  embedded,  felt  at  the  instant  of  pulling  the  trigger 
a  sense  of  general  numbness  and  then  of  deep-seated  pain 
in  both  ears.  In  still  another  case  of  pistol-shot  wound  of 
the  frontal  region,  in  which  both  lobes  had  suffered  exten- 
sive laceration,  the  suicidal  person  was  enabled  long  after- 
ward not  only  to  analyze  his  thoughts  at  the  moment  the 
injury  was  inflicted,  but  to  recall  the  impression  upon  his 
mind  of  the  almost  simultaneous  shriek  of  his  mother 
from  an  adjacent  room.  He  was  suffering  from  melan- 
cholia with  a  feeling  of  oppression  in  his  head,  which  was 
the  immediate  incentive  to  self-destruction.  The  act  was 
deliberate,  and,  while  he  was  not  unmindful  of  his  family, 
the  discomfort  he  felt  in  the  top  of  his  head  was,  as  he  ex- 
pressed it,  "uppermost  in  his  mind."  He  remembered 
his  mother's  cry  at  the  report  of  the  pistol,  but  had  no 
further  definite  recollection  of  what  occurred  till  he 
"  awoke"  twenty-three  days  later  in  the  infirmary  to  which 
he  had  been  removed ;  and  yet  for  the  first  two  weeks  he 
was  apparently  rational  and  in  full  possession  of  all  his 
intellectual  faculties.  After  a  subsequent  period  of  mental 
disorder  with  delusions  and  paroxysms  of  acute  mania  he 
was  apparently  quite  recovered  at  the  end  of  the  fifth 
month  (Sloane). 

This  case,  which  was  recorded  with  unusual  care  by 
his  medical  attendant,  demonstrates  that  even  with  ex- 
tensive destruction  of  the  psychical  centres  neither  the 
perceptional    nor    the    ideational   powers   are    necessarily 


340  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

suspended  for  the  minutest  conceivable  measure  of  time. 
The  cry  was  heard  and  its  source  recognized,  which  in- 
volved a  reasoning  process,  in  the  time  required  for  sound 
to  traverse  twice  the  distance  between  two  adjacent  rooms ; 
for,  as  instinct  is  even  quicker  than  thought,  no  appreci- 
able interval  could  have  intervened  between  the  mother's 
perception  of  the  report  of  the  pistol  and  her  instinctive 
response. 

This  history  parenthetically  illustrates  the  unsuspected 
enfeeblement  of  will  and  incapacity  of  judgment  which 
may  really  exist  in  a  case  of  apparently  simple  melan- 
cholia, and  in  this  instance  permitted  the  man  to  believe 
that  an  absurdly  trivial  ill  so  far  transcended  all  the  obli- 
gations and  interests  of  life  as  to  make  it  not  worth  the 
living,  and  left  him  powerless  to  restrain  his  suicidal  im- 
pulse. His  later  mental  condition  was  in  one  respect 
anomalous.  In  the  period  immediately  succeeding  the 
injury  it  was  believed  to  be  absolutely  normal.  After  a 
consecutive  longer  period  of  acute  mania  and  apparently 
settled  aberration,  his  mind  was  permanently  restored,  ex- 
cept that  his  memory  was  wanting  so  far  as  it  concerned 
the  previous  rational  interval.  It  is  usually  the  remem- 
brance of  events  directly  connected  with  the  infliction  of  a 
grave  cerebral  injury  that  is  temporarily  or  permanently 
lost,  and  subsequent  events,  if  forgotten  for  a  time,  are  re- 
called before  the  reparative  stage  is  ended.  In  the  case  of 
this  patient,  memory  was  perfect  for  everything  that  had 
been  felt  or  done  until  an  instant  after  the  wound  was  in- 
flicted, and  partially  retained  for  occurrences  during  the 
maniacal  episode,  but  a  hiatus  was  complete  as  to  the 
rational  period  which  intervened  between  the  condition  of 
melancholia  and  the  access  of  mania.     How  far  his  aber- 


SURGICAL   RELATIONS.  341 

rations  depended  upon  traumatism  and  how  far  upon  the 
progress  of  his  prior  mental  infirmity,  it  is  of  course  im- 
possible to  decide. 

These  phenomena  scarcely  belong  to  the  consideration 
of  the  primary  symptoms  of  pistol-shot  wounds  of  the 
brain,  but  are  not  altogether  impertinent,  in  view  of  the 
relation  which  so  frequently  subsists  between  such  wounds 
and  mental  disorder. 

If  the  first  effects  of  injury  be  survived,  there  is  no  es- 
sential variation  in  the  course  of  symptoms  as  it  has  been 
noted  in  the  general  class  of  brain  lacerations.  Conscious- 
ness is  perhaps  less  frequently  retained,  vomiting  of 
rather  more  frequent  occurrence,  and  pain  in  the  head 
more  severe.  Death  may  result  from  the  continuance  of 
intracranial  hemorrhage,  or  from  the  direct  inhibitory 
action  of  laceration  and  attendant  general  contusion  upon 
the  vital  cerebral  functions.  In  a  much  smaller  propor- 
tion of  cases  these  dangers  are  safely  passed  only  to  give 
place  to  others,  scarcely  less  formidable,  which  attend 
retrograde  nutritive  changes  in  the  cerebral  tissue.  Soft- 
ening and  abscess  with  paralysis,  mental  deterioration,  and 
epilepsy  may  follow  in  the  course  of  time,  with  their  usual 
symptoms  in  no  degree  modified  by  the  nature  of  the 
original  traumatism.  The  localizing  symptoms  which 
may  be  at  any  time  manifested,  in  consequence  either  of 
limited  lesions  in  the  track  of  injury  or  of  the  presence  of 
the  ball  at  the  point  at  which  it  is  lodged,  equally  conform, 
to  rule  as  established  in  the  general  symptomatology  of 
intracranial  injuries. 


342        injuries  of  the  brain  and  membranes. 

Diagnosis. 

The  problem  of  diagnosis  distinctively  concerns  but 
a  single  point,  the  location  of  the  bullet  when  it  still  re- 
mains within  the  cranial  cavity.  The  nature  of  the  trau- 
matism, the  circumstances  under  which  the  wound  has 
been  inflicted,  the  point  at  which  the  cranium  has  been 
penetrated,  and  the  direction  which  the  missile  has  taken, 
have  all  been  elucidated  so  far  as  it  has  been  possible,  in 
the  study  which  has  been  made  of  the  external  wound  in 
its  medico-legal  relations,  and  are  independent  of  intra- 
cranial conditions.  The  character  and  extent  of  the 
lesions  produced  by  the  bullet  in  its  passage  through  the 
brain  and  appendages  can  be  determined  by  no  different 
means  than  have  heretofore  served  for  the  estimation  of 
similar  lesions  of  different  origin.  As  they  have  been 
manifested  by  the  same  symptoms  in  either  case,  they 
must  be  recognized,  if  at  all,  by  giving  these  symptoms  an 
identical  interpretation.  The  location  of  a  bullet  which 
has  failed  of  exit  alone  demands  special  diagnostic  consid- 
eration, and  involves  the  employment  of  special  methods 
of  investigation.  It  is  sometimes  easily  accomplished, 
oftener  with  difficulty,  and  oftener  still  it  is  impossible. 
Any  effort  directed  to  this  end  is  necessarily  deferred  un- 
til the  immediate  safety  of  the  patient  is  assured.  If,  after 
the  partial  restoration  of  consciousness,  localizing  symp- 
toms become  apparent  which  can  be  disassociated  from 
lesions  caused  by  the  bullet  while  still  in  motion,  they  are 
practically  pathognomonic.  The  occurrence  of  limited 
paralysis  upon  the  side  of  the  body  corresponding  to  a 
wound  of  entrance,  for  example,  in  the  temporal  region, 
with  the   corroboration   which   might  be   afforded  by  the 


SURGICAL    RELATIONS.  343 

axis  of  the  cerebral  wound,  would  point  with  great  cer- 
tainty to  the  lodgement  of  the  bullet  in  a  designated  part 
of  the  motor  area.  In  like  manner  the  existence  of  motor 
or  sensory  aphasia,  or  at  a  later  period  the  occurrence  of 
certain  disorders  of  vision,  might  equally  indicate  its  loca- 
tion in  a  definite  part  of  a  speech  or  visual  area.  The  in- 
stances in  which  dependence  may  be  placed  upon  cerebral 
localization  are  after  all  comparatively  infrequent.  The 
extent  of  cortical  area  which  as  yet  must  be  regarded  as 
latent  or  of  indeterminate  function  is  so  great,  and  the 
further  probability  that  the  bullet  will  rest  in  some  sub- 
cortical region  is  so  strong,  that  such  aid  is  hardly  to  be 
expected.  In  another  small  proportion  of  cases  a  clew  to 
the  position  of  the  bullet  may  be  had  in  a  discoverable  in- 
jury to  the  opposite  wall  of  the  cranium.  This  may  be 
more  or  -less  evident ;  the  scalp  may  be  contused  above  it 
or  the  bone  obviously  elevated,  or  there  may  be  only  a 
tender  spot,  beneath  which  after  incision  some  fine  fissures 
may  be  detected.  The  shaving  of  the  head,  which  is  prac- 
tised as  a  part  of  the  routine  of  treatment  in  all  intra- 
cranial injuries,  permits  careful  examination,  and  will 
probably  insure  the  discovery  of  any  lesion  which  in- 
cludes the  external  table. 

The  main  reliance  of  the  surgeon  in  this  investigation 
must  be  upon  the  use  of  the  probe,  by  which  it  is  sought 
to  trace  the  bullet  from  its  osseous  entrance  to  its  point 
of  lodgement.  This  method  of  exploration  of  gunshot 
wounds  as  they  affect  important  visceral  cavities  has  been 
much  and  properly  criticised,  but  the  procedure  is  in  itself 
proper,  and  the  limitations  to  which  it  is  subject  concern 
the  consideration  of  treatment  rather  than  of  diagnosis. 
The  instrument  is  variously  adapted  to  its  purpose;  the 


344  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

ordinary  one  of  silver  which  is  employed  for  general  sur- 
gical exploration  is  supplemented  by  those  of  Fluhrer, 
Nelaton,  and  Girdner,  Fluhrer's  probe,  like  the  one  in 
more  common  use,  is  designed  for  general  exploration,  but 
is  differently  constructed.  Nelaton 's  and  Girdner's  are 
both  intended  not  only  to  detect  the  presence  of  a  foreign 
body  in  the  tissues  but  to  determine  its  metallic  character. 

Fluhrer's  probe  is  so  fashioned  as  to  obviate  some  of 
the  disadvantages  which  are  found  to  attach  to  the  use  of 
the  commoner  instrument.  It  is  of  large  size,  tapering 
toward  two  bulbous  extremities ;  it  is  twelve  inches  long, 
and  in  diameters  one-eighth  of  an  inch  at  its  middle,  and 
one-fourth  and  one-eighth  of  an  inch  respectively  in  its 
larger  and  smaller  terminal  bulbs.  Its  shaft  is  rigid,  and 
its  weight  is  lightened  by  the  use  of  tempered  aluminium 
in  place  of  silver.  The  ends  are  made  large  in  order  to 
diminish  the  danger  of  wounding  the  tissues  and  of  making 
false  passages ;  the  shaft  is  made  rigid  in  order  that  its 
relation  to  the  bulbous  ends  shall  be  fixed ;  and  its  weight 
is  made  light  in  order  to  transmit  without  loss  delicate 
vibrations  to  the  hand. 

The  probe  of  Nelaton,  by  reason  of  its  capability  of  re- 
ceiving and  retaining  a  lead  stain,  has  been  long  used  to 
determine  the  fact  that  a  foreign  body  is  a  leaden  bullet. 
It  is  a  simple  ball  of  unglazed  porcelain  at  the  end  of  a 
flexible  silver  stem ;  it  may  be  of  any  size,  but  is  usually 
of  about  one-eighth  of  an  inch  in  diameter.  It  acts  as  an 
ordinary  probe  in  detecting  the  foreign  substance,  and 
specifically  determines  its  nature  by  acquiring  or  escaping 
the  peculiar  stain  of  lead  as  the  two  substances  are  firmly 
pressed  or  rubbed  together.  The  porcelain  will  be  stained 
always  if  actual  contact  can  be  obtained ;  but  the  practical 


SURGICAL    RELATIONS.  345 

difficulty  and  possible  source  of  error  lies  in  the  fact  that 
this  contact  cannot  be  positively  assured.  It  is  found  in 
practice  that  the  surface  of  the  bullet  may  be  so  protected 
by  blood  and  shreds  of  tissue,  and  the  surface  of  the  por- 
celain so  smeared  by  the  fluids  of  the  part,  that  while  the 
impact  upon  a  hard  body  may  be  evident  the  character- 
istic stain  may  be  wanting.  The  positive  evidence  which 
it  affords  is  unquestionable,  but  its  failure  to  demonstrate 
the  presence  of  lead  does  not  equally  prove  that  the  hard 
body  felt  is  not  a  bullet. 

Girdner's  telephonic  probe,  which  is  of  comparatively 
recent  introduction,  like  that  of  Nelaton,  acts  as  an  ordi- 
nary probe,  and  at  the  same  time,  when  the  foreign  body 
embedded  in  the  tissues  is  a  bullet,  demonstrates  its  metal- 
lic nature  by  the  grating  sound  produced  from  the  inter- 
ruptions of  an  electric  current  established  through  it,  the 
circuit  being  formed  by  tlje  probe  in  the  hand  of  the  oper- 
ator, a  battery,  and  a  bulb  in  the  mouth  of  the  patient. 
Every  precaution  of  course  must  be  taken  to  insure  the 
continuity  of  the  current  except  as  it  is  broken  upon  the 
surface  of  the  concealed  object  when  the  end  of  the  instru- 
ment passes  over  its  inequalities.  The  receiver  is  held  to 
the  ear  with  one  hand,  while  the  probe  is  guided  with  the 
other.  This  instrument  is  now  sufficiently  well  known  to 
require  no  more  detailed  description.  If  contact  be  made 
with  the  alien  substance,  it  cannot  fail  positively  to  deter- 
mine whether  or  not  it  be  the  bullet,  and  in  this  has  mani- 
fest advantage  over  the  device  of  Nelaton.  There  can  be 
no  doubt  of  its  value  in  gunshot  wounds  of  other  regions 
of  the  body,  as  in  the  extremities  or  in  the  neighorhood  of 
the  spinal  column,  when  to  decide  this  question  is  to  de- 
cide the  question  of  operation.     It  has  less  practical  im- 


346  IN'JURIES    OF   THE   BRAIN   AND    MEMBRANES. 

portance  in  case  of  brain  wounds,  in  which  a  fragment  of 
bone  carried  into  the  substance  of  the  organ  may  be  as 
much  a  menace  to  life  as  is  the  bullet  itself.  In  the  nu- 
merous instances  in  which  the  position  of  a  foreign  body 
cannot  be  determined  it  can  be  of  no  avail,  because  contact 
is  an  essential  condition.  Its  usefulness  is  limited,  there- 
fore, not  only  since  it  does  not  necessarily  make  the  sur- 
geon's position  clearer  as  regards  the  propriety  of  opera- 
tion, but  as  it  fails  of  even  the  possibility  of  very  general 
application.  In  wounds  of  the  basilar  and  mastoid  proc- 
esses, and  of  the  petrous  portion,  or  when  the  bullet  has 
lodged  in  the  basic  fossae  without  having  penetrated  the 
dura,  or  in  the  orbit,  it  may  be  of  the  greatest  service.  If 
it  were  possible  for  the  electric  current  to  make  manifest 
the  vicinage  of  a  bullet  to  which  it  could  not  quite  be 
made  to  reach,  it  might  more  nearly  solve  one  of  the  still 
difficult  problems  in  surgery.  It  has  been  sought  to  deter- 
mine in  this  way  the  location  of  bullets  in  the  brain,  as 
well  as  elsewhere,  by  means  of  an  instrument  known  as  the 
induction  balance.  In  the  opinion  of  Dr.  Girdner,  who 
has  given  it  much  attention,  this  mechanism  is  so  delicate 
in  construction  and  so  easily  deranged  that  it  can  be  made 
effective  only  in  the  hands  of  a  professional  electrician. 
It  would  seem,  therefore,  that  it  must  take  its  place  with 
other  surgical  appliances  of  theoretical  value  which  are  too 
complex  for  practical  general  use. 

If  the  cerebral  wound  be  large,  and  especially  if  not  too 
deep,  the  finger,  when  confined  within  the  limit  of  lacera- 
tion, may  prove  the  best  instrument  of  exploration. 

The  use  of  the  Rontgen  rays  for  determining  the  posi- 
tion of  a  bullet  within  the  cranial  cavity  has  thus  far  been 
attended  with   little  success.     Two  cases  have  been   re- 


SURGICAL    RELATIONS.  347 

ported  by  Dr.  A.  Eulenberg  during  the  past  year  (1896),  in 
which  by  a  new  process  of  Dr.  Buka,  of  Charlottenburg,  the 
location  of  the  missile  seems  to  have  been  demonstrated. 
In  both  instances  a  wound  had  been  inflicted  in  the  right 
temporal  region  by  a  pistol  shot  of  small  calibre.  In  one 
of  them  exposure  to  the  rays  was  made  a  few  weeks  after 
injury,  and  in  the  other  not  till  after  the  lapse  of  ten 
years.  In  one,  symptoms  indicated  lesion  of  the  right  side 
of  the  brain,  and  in  the  other  no  such  localizing  indica- 
tions existed.  The  only  apparently  successful  instance  of 
the  employment  of  this  process  for  the  detection  of  a  bullet 
in  the  brain,  which  has  been  reported  in  America,  is  one 
occurring  in  the  service  of  Dr.  Willy  Meyer  in  the  Ger- 
man Hospital  of  New  York.  The  patient,  whose  early 
history  is  recorded  in  Case  CCC.  of  the  appended  series, 
was  some  time  after  his  discharge  from  Bellevue  Hospital, 
and  at  a  date  later  than  that  of  Eulenberg's  cases,  sub- 
jected by  Dr.  Meyer  to  the  Rontgen  test,  with  the  dis- 
covery of  three  minute  objects  in  the  frontal  lobes,  and  in 
line  with  each  other,  two  of  which  were  believed  by  him 
to  be  fragments  of  the  bullet.  In  neither  of  the  cases  re- 
ported by  Eulenberg  or  Meyer  was  the  result  verified 
by  subsequent  operation  or  necropsic  examination.  The 
subject  of  the  case  last  mentioned  again  became  a  patient 
in  Bellevue  Hospital,  but  was  for  various  reasons  deemed 
unfit  for  operative  interference. 

It  is  not  improbable  that  the  development  of  this  form 
of  photography  may  in  the  future  add  greatly  to  the  cer- 
tainty with  which  intracranial  foreign  bodies  can  be  dis- 
covered and  their  position  accurately  determined ;  it  seems 
less  certain  that  by  thus  increasing  the  possibility  of  posi- 
tive diagnosis  it  will  equally  add  to  the  resources  and  sue- 


348  INJURIES    OF    THE    BRAIN   AND    MEMBRANES. 

cess  of  treatment.  Increased  perfection  of  method  and 
apparatus  will  tend  to  remove  it  still  farther  from  the  uses 
of  private  practice,  except  in  cases  in  which  recovery  has 
been  had  from  the  immediate  effects  of  injury.  In  hos- 
pitals, where  it  might  otherwise  be  available,  the  condition 
of  the  patient  will  be  likely  to  preclude  its  employment  at 
the  outset,  w^hen  operation,  if  not  imperative,  will  at  least 
afford  the  best  prospect  of  a  successful  issue.  If  the  mis- 
sile or  fragment  of  bone  is  superficially  situated,  it  should 
be  discovered  and  removed  at  once  without  the  necessity 
of  resort  to  other  than  ordinary  means;  if  more  deeply 
embedded,  and  undiscovered  at  the  time  when  exposure  to 
the  light  rays  has  become  practicable,  success  in  the  dis- 
closure of  the  bullet  will  still  leave  special  operative  diffi- 
culties to  be  encountered.  The  original  cerebral  wound 
will  probably  have  been  closed,  and  after  the  exact  loca- 
tion of  the  bullet  has  been  fixed  at  the  intersection  of  dif- 
ferent planes  of  view,  it  may  be  far  from  easy  to  utilize 
this  conception  in  the  mind  of  the  operator  for  making  a 
new  and  lengthened  incision  with  the  precision  which  is 
essential  for  the  justification  of  so  serious  a  procedure.  It 
is  idle,  however,  to  speculate  upon  the  practical  applica- 
tion of  as  yet  unattained  results  in  scientific  progress ;  new 
conditions  may  conceivably  involve  the  use  of  more  facile 
and  widely  applicable  instrumentalities,  but  at  the  pres- 
ent time  no  demonstrated  advantage  has  accrued  in  this 
department  of  surgery  from  the  Rontgen  process  of  pho- 
tography. 

A  final  diagnostic  method  consists  in  thrusting  a  sharp 
needle  into  the  cerebral  tissue,  not  quite  at  random,  but 
in  directions  which  there  may  be  reason  to  suppose  the 
bullet  has  taken.     If  perfect  asepsis  has  been  secured,  this 


SURGICAL    RELATIONS.  349 

may  ordinarily  be  done  with  safety  and  the  bullet  possi- 
bly discovered.  It  is  a  legitimate  procedure,  recognized 
in  general  cerebral  surgery,  but  should  be  resorted  to 
advisedly  and  with  great  discretion.  If  the  bullet  cannot 
be  reached  through  the  cerebral  wound,  and  there  are  at 
the  same  time  localizing  general  symptoms  or  other  indi- 
cations which  point  to  its  approximate  position,  it  may  be 
properly  sought  in  this  manner,  but  reckless  punctures 
of  the  brain  which  are  uninspired  by  some  intelligently 
directed  purpose  are  scarcely  justified  by  the  slender 
chance  of  their  accidental  success. 

These  several  methods  of  search,  guided  by  the  obser- 
vation of  existing  localizing  symptoms  or  of  indications  of 
injury  to  the  opposite  cranial  wall,  are  the  only  means 
available  for  the  discovery  of  the  bullet.  Their  successful 
use  requires  not  only  manual  skill,  but  quickness  of  percep- 
tion and  sagacity  of  interpretation  in  the  study  of  the  often 
obscure  attendant  conditions. 

It  has  been  assumed  that  the  bullet  in  its  passage 
through  the  brain  is  likely  to  be  diverted  from  its  direct 
course  by  trivial  obstacles,  as  is  known  to  be  the  case  in  the 
extremities  or  in  certain  regions  of  the  trunk.  This  con- 
tingency is  in  fact  less  to  be  expected  within  the  cranial 
cavity  than  elsewhere.  The  density  of  the  brain  substance 
is  very  much  the  same  from  one  surface  to  another,  and  it 
is  found  in  both  ante-mortem  and  cadaveric  wounds  that 
the  reflections  of  the  dura  mater  are  usually  penetrated 
without  the  direction  of  the  bullet  having  been  changed. 
There  are  not  wanting  instances  in  which  it  has  been  de- 
flected by  the  falx  cerebri,  or  in  which,  having  entered  a 
dural  sinus,  it  has  traversed  it  to  the  end,  but  these  are 
exceptional.     It  is  nevertheless  the  fact  that  in  a  consider- 


350  INJURIES    OF   THE   BRAIN    AND    MEMBRANES. 

able  proportion  of  cases  the  bullet  which  fails  of  exit  is 
turned  aside  from  its  direct  course.  The  change  im- 
pressed upon  its  direction  is  due,  not  to  deep  intracranial 
obstruction,  but  to  the  resistance  offered  by  the  cranial  wall 
and  dura  mater  at  its  entrance,  or  by  the  same  structures 
upon  which  it  may  impinge  at  a  point  upon  the  opposite 
side  of  the  head.  A  bullet,  especially  if  of  small  size,  with 
or  without  penetration  of  the  dura  mater,  is  often  at  once 
deflected  at  a  right  angle,  or  if  of  larger  size,  after  travers- 
ing the  brain  and  having  insufficient  force  to  penetrate 
the  opposite  dural  wall,  falls  back  into  the  track  and  is 
diverted  perhaps  to  a  considerable  distance  in  some  new 
direction.  It  may  be  that  it  drops  directly  downward 
through  the  cortex  or  immediately  subjacent  tissue 
toward  the  base,  or  it  may  quite  as  probably  take  some  un- 
discoverable  course  which  leads  to  inaccessible  cerebral 
depths.  In  any  attempt  at  exploration  of  a  cerebral  wound 
to  discover  the  location  of  the  bullet,  it  should  be  borne  in 
mind  that  it  is  not  in  the  central  part  of  the  brain  that  it 
is  most  likely  to  go  astray.  If  the  wound  can  be  traced 
directly  inward  for  an  inch  or  more,  while  it  is  still  possi- 
ble than  an  elusive  pistol  ball  may  have  been  deflected  by 
a  dural  reflection,  or  have  stopped  short  from  exhausted 
force  at  any  point  just  out  of  reach,  it  is  more  probable 
that  it  has  gone  straight  onward  at  least  as  far  as  the  op- 
posite dural  wall,  and  that  further  search  must  involve  a 
new  departure.  The  larger  the  ball  the  more  likely  is  this 
generalization  to  prove  true  in  an  individual  case. 

In  a  wound  involving  the  anterior  temporal  region  espe- 
cial heed  should  be  given  in  doubtful  cases  to  the  condition 
of  the  eye  and  to  the  orbit.  Sight  may  have  been  de- 
stroyed by  an  injury  of  the  optic  nerve  at  the  optic  fora- 


SURGICAL    RELATIONS.  35  I 

men,  and,  in  the  absence  of  ocular  hemorrhage  or  other 
apparent  ocular  or  orbital  changes,  escape  discovery  unless 
the  parts  are  subjected  to  systematic  examination.  The 
lack  of  attention  to  these  local  indications,  in  one  case  at 
least,  has  permitted  the  resort  to  serious  operation  in  the 
vain  search  of  the  brain  for  a  bullet,  the  presence  of  which 
in  the  orbit  was  evident,  but  ignored  because  it  failed  to 
respond  to  the  electric  test.  Considerable  hemorrhage  in 
the  post-orbital  region,  causing  discoloration  of  the  lids 
and  protrusion  of  the  eye,  is  not  to  be  lightly  disregarded ; 
and  the  suspicion  which  they  engender  may  be  strength- 
ened by  the  direction  which  the  bullet  may  be  found 
to  have  taken  from  the  point  at  which  it  entered  the 
brain. 

It  is  also  possible  that  the  bullet  should  escape  from  the 
cranial  cavity  in  some  region  of  the  base  which  is  beyond 
the  possibility  of  direct  examination.  This  may  be  de- 
tected in  rare  instances,  as  it  was  in  Case  CCXCIX.,  by 
passing  the  probe  through  the  whole  length  of  the  cere- 
bral wound  and  through  the  osseous  exit.  Such  a  lodge- 
ment of  the  ball  can  ordinarily  only  be  suspected,  and  con- 
firmation can  be  had  only  in  the  recovery  of  the  patient. 
It  is  sufficient  to  recognize  the  possibility  of  this  issue  to 
give  perhaps  a  new  significance  to  apparently  trivial  signs 
and  symptoms,  and  sometimes  to  make  easy  the  interpre- 
tation of  an  otherwise  inexplicable  case.  Pain  or  swelling 
in  some  cervical  region,  or  functional  disability  of  the 
muscles  there  or  in  the  pharynx,  with  some  dysphagia  or 
dyspnoea,  without  apparent  cause,  together  with  unex- 
pectedly inconsiderable  or  improving  cerebral  symptoms 
following  a  wound,  perhaps  in  the  mastoid  or  inferior  tem- 
poral region,  through  which  the  ball  has  passed  in  an  an- 


352  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

swerable  direction,  make  up  a  picture  distinct  enough  if  it 
be  but  seen  in  proper  focus. 

The  antithetical  case  in  which  the  bullet  passes  through 
the  mouth  or  neck  or  even  through  the  eye  to  penetrate 
the  cranial  base  is  occasionally  difficult  of  diagnosis.  Or- 
dinarily in  such  a  wound,  its  evident  nature,  or  the  imme- 
diate occurrence  of  characteristic  symptoms,  so  plainly 
mark  the  intracranial  complication  that  the  diagnostic 
problem  is  solved  before  it  has  really  challenged  thought. 
In  the  exceptional  case  it  may  be  impossible  to  follow  the 
track  of  the  ball  or  even  to  surmise  its  course,  while  the 
general  condition  of  the  patient  may  cause  vague  suspicion 
of  some  hidden  lesion ;  or  after  an  interval  devoid  of 
S5''mptoms  some  decided  change  occurs,  a  notable  and  con- 
tinued rise  in  temperature  it  may  be,  for  which  the  closest 
scrutiny  of  accessible  regions  affords  no  adequate  expla- 
nation. 

There  are  no  formal  rules  to  follow  in  the  examination 
of  the  doubtful  cases  in  which  the  bullet  may  have  escaped 
from  the  cranial  cavity  into  inaccessible  adjacent  parts,  or 
in  which  from  primary  wounds  of  those  parts  the  bullet 
may  have  terminated  its  course  within  the  cranial  walls. 
It  is  necessary  for  the  surgeon  to  be  at  once  alert  and  sus- 
picious in  the  presence  of  symptoms  of  uncertain  signifi- 
cance, to  bear  well  in  mind  all  the  possibilities  connected 
with  the  whereabouts  of  vagrant  bullets,  and  to  be  wary  in 
the  formation  of  opinions  while  premises  are  not  yet  posi- 
tively settled. 


surgical  relations.  353 

Treatment. 

The  consideration  of  treatment  may  properly  precede 
that  of  prognosis,  and  may  be  essentially  limited  to  that 
division  of  the  subject  which  concerns  the  question  of  in- 
terference or  non-interference  with  the  bullet  when  re- 
tained within  the  cranial  cavity.  The  management  of  the 
lesions  which  the  bullet  has  produced  involves  no  new 
principles,  and  is  not  different  from  that  which  has  been 
prescribed  for  the  same  cerebral  conditions  when  they 
have  resulted  from  ordinary  forms  of  violence ;  it  is  there- 
fore unnecessary  in  the  present  connection  to  reconsider 
its  details. 

The  inception  of  any  treatment  comes  in  question  in 
only  a  minority  of  cases ;  passing  those  in  which  death  has 
been  nearly  or  quite  instantaneous,  and  those  in  which  it 
is  so  obviously  imminent  that  there  is  room  only  for  the 
simple  offices  of  humanity,  but  few  remain  in  which  the 
surgeon  is  called  upon  to  treat  primary  shock  and  hemor- 
rhage. The  recumbent  position,  the  application  of  exter- 
nal heat,  the  hypodermic  exhibition  of  cardiac  stimulants, 
the  use  of  hot  saline  enemata,  or  the  resort  to  transfusion, 
and  at  the  same  time,  if  it  be  possible,  the  repression  of 
hemorrhage,  are  here  as  elsewhere  the  means  at  his  dis- 
posal. Until  the  establishment  of  reaction  nothing  more 
remains  to  be  done.  Thus  far  the  procedure  is  the  same  as 
it  would  be  for  other  surgical  injuries ;  the  general  treat- 
ment of  shock  is  scarcely  modified  by  the  nature  or  loca- 
tion of  a  wound ;  and  the  necessity  of  postponing  surgical 
interference,  except  for  the  control  of  hemorrhage,  until 
after  the  restoration  of  nervous  force,  must  be  regarded  as 

a  fundamental  law  in  surgery.     Usually  if  hemorrhage  is 
23 


354  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

sufficient  to  be  matter  of  serious  concern  it  will  be  uncon- 
trollable, but  it  may  be  derived  in  some  or  even  greater 
part  from  the  vessels  of  the  scalp,  which  may  be  then  easily 
secured  by  ligature.  There  are  perhaps  cases  in  which 
intracranial  hemorrhage,  though  moderate,  is  persistent, 
and  in  which  temporary  plugging  of  the  intracranial  wound 
with  aseptic  gauze  is  justifiable,  as  it  is  in  operative 
wounds  inflicted  upon  the  brain.  If  resort  is  to  be  made 
to  this  means  of  hsemostasis,  great  care  should  be  exercised 
to  prevent  the  further  escape  of  blood  from  the  cerebral 
wound  into  the  arachnoid  and  epidural  spaces. 

At  the  same  time  that  restorative  measures  are  being 
employed,  and  as  opportunity  is  afforded,  external  lesions 
should  be  scrutinized,  both  for  medico-legal  reasons  and 
for  guidance  in  subsequent  surgical  procedure.  The 
smoke  stain,  the  unburned  grains  of  powder  upon  the  sur- 
face, and  slight  traces  of  flame  are  so  easily  lost  that 
when  present  they  should  be  noted  at  the  earliest  possible 
moment.  The  original  characteristics  of  the  external 
wound  are  liable  to  alteration  and  therefore  should  also 
receive  immediate  attention. 

The  further  treatment  of  these  cases  has  been  the  sub- 
ject of  varied  opinion,  and  is  still  based  upon  widely  dif- 
ferent views  of  surgical  propriety.  It  has  been  held: 
First,  that  the  wound  should  be  left  absolutely  undis- 
turbed, and  intrusted  to  the  simplest  form  of  external 
aseptic  dressing,  since  the  dangers  of  interference  out- 
weigh any  which  may  result  from  the  direct  cerebral  in- 
jury or  from  the  retention  of  a  foreign  body.  This  may 
be  regarded  as  an  ultra-conservative  and  traditional  judg- 
ment unmodified  by  changed  conditions  of  surgical  prac- 
tice.    Second,  that  while  operative  interference  may  be- 


SURGICAL    RELATIONS.  355 

come  a  necessity,  its  only  justification  -will  exist  in  the 
establishment  of  drainage,  and  that  the  removal  of  the 
bullet  is  of  minor  or  no  importance,  since  it  is  in  itself 
harmless,  having  accomplished  all  the  mischief  of  which 
it  is  capable  in  the  infliction  of  the  wound.  This  is  a 
semi-recognition  of  the  fact  that  aseptic  methods  are  de- 
manded for  the  successful  management  not  only  of  wounds 
of  the  surface  but  of  the  cavities  and  viscera  of  the  body. 
Third,  that  the  condition  of  the  superficial,  cranial,  dural, 
and  cerebral  wounds  should  be  subjected  to  thorough  ex- 
amination, fragments  of  bone  removed,  drainage  insured 
when  necessary,  and  the  bullet,  if  possible,  extracted. 
This  course  of  procedure  is  in  accordance  with  general 
surgical  practice  at  the  present  time,  and  is  founded  upon 
a  belief  that  asepsis  demands  absolute  cleanliness,  and  that 
its  laws  are  of  universal  application  and  are  to  be  enforced 
in  their  integrity. 

These  several  views  of  the  proper  plan  of  treatment  of 
cerebral  wounds  of  this  character  have  been  clearly  as- 
serted, and  the  results  of  their  practical  application  fully 
illustrated  in  the  reports  of  cases  published  during  the 
past  sixteen  years.  Such  a  series  of  clinical  observations 
affords  the  only  ground  for  opinion,  aside  from  theoretical 
considerations  based  upon  the  general  principles  of  sur- 
gery. The  one  hundred  and  thirty-six  cases  collected 
represent  the  almost  entire  published  experience  of  Eng- 
lish, Colonial,  and  American  practitioners  since  the  adop- 
tion of  thorough  aseptic  methods  in  surgery,  and  include 
twenty-six  taken  from  the  personal  records  which  so  largely 
form  the  basis  for  the  present  study  of  general  intracra- 
nial lesions. 

The  principles  of  surgical   practice   are   so  well  estab- 


356  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

lished  that  it  would  seem  scarcely  necessary  to  insist  upon 
the  propriety  of  exploration  of  the  external  and  cranial 
wounds,  and  the  removal  thence  of  fragments  of  bone  and 
other  foreign  bodies,  if  some  of  the  most  recently  reported 
cases  had  not  shown  that  this  simple  procedure  is  still  often 
neglected.  There  is  no  reason  a  priori  why  these  partic- 
ular wounds  should  be  made  exceptions  to  accepted  gen- 
eral rules  of  treatment,  and  the  only  conceivable  justifica- 
tion, if  any  existed,  would  have  to  be  found  in  the  results 
obtained  in  actual  practice.  An  examination  of  this  entire 
series  of  cases  faills  to  disclose  any  instance  in  which  a 
conformity  to  rule  in  this  respect  has  inured  to  the  preju- 
dice of  the  patient,  but  evidently  its  neglect  has  often 
entailed  a  fatal  result. 

Death  occurred  in  forty-two  out  of  seventy  cases  in 
which  no  operation  was  performed.  In  ten  of  these  re- 
action was  never  sufficiently  established  to  justify  interfer- 
ence ;  and  in  five  the  history  is  not  sufficiently  detailed 
to  determine  whether  operation  was  done,  and,  if  not, 
whether  its  omission  was  responsible  for  the  result.  In  at 
least  seven  of  the  remaining  twenty-seven  cases,  death  can 
be  directly  traced  to  the  want  of  exploration  and  of  thor- 
ough aseptic  treatment  of  the  osseous  and  superficial  cere- 
bral wound. 

The  necropsic  conditions  were : 

Case  I. — A  mass  of  bone  piercing  the  dura  and  brain, 
with  a  superficial  cavity  containing  the  bullet  and  pus,  and 
a  nearby  abscess  in  the  frontal  lobe. 

Case  II.. — Many  osseous  fragments  embedded  in  the 
brain  and  a  wound  of  the  middle  meningeal  artery,  v;hich 
was  the  direct  cause  of  death  twelve  hours  later. 

Case  III. — Operation  on  the  forty-seventh  day  and  the 


SURGICAL   RELATIONS.  357 

removal  of  small  osseous  fragments  from  the  frontal  region 
with  discharge  of  a  purulent  fluid.  The  bullet  on  necrop- 
sic  examination  was  found  to  be  encysted  in  the  cere- 
bellum. 

Case  IV. — Superficial  caAdty  containing  the  bullet, 
fragments  of  bone,  and  a  sero-purulent  fluid. 

Case  V. — Large  fragments,  composed  of  both  osse- 
ous tables,  driven  into  the  brain,  and  contiguous  ab- 
scess. No  cerebral  change  at  the  site  of  the  distant 
bullet. 

Case  VI. — Large  fragments  of  bone  removed  by  oper- 
ation in  the  eighth  month.  Necropsy  six  days  later;  sub- 
cutaneous suppuration  and  localized  meningitis;  large 
abscess  in  subjacent  temporal  lobe. 

Case  VII. — A  depressed  dural  cicatrix,  containing  os- 
seous fragments  and  a  piece  of  lead.  The  remainder  of 
the  bullet  was  subcutaneous. 

In  another  case,  classed  among  the  fatalities  following 
early  operation,  an  osseous  fragment  was  removed  on  the 
eighth  day  with  a  considerable  discharge  of  pus.  Death 
occurred  from  sepsis  some  time  afterward. 

In  two  instances  there  was  apparent  recovery  before 
the  development  of  the  fatal  symptoms. 

These  cases  are  perhaps  not  to  be  regarded  as  statisti- 
cally denoting  the  fatality  which  results  from  the  neglect 
of  this  simplest  form  of  operative  interference ;  the  pro- 
portion of  reported  cases  to  the  whole  number  of  pistol- 
shot  wounds  of  the  cranial  contents  is  too  small.  They 
are  quite  sufficient  to  establish  the  fact  that  osseous  frag- 
ments resting  upon  the  cerebral  surface  or  penetrating  the 
cerebral  cortex  may  be  more  dangerous  than  the  bullet 
itself;   that  there  is  no  safety  in  the  absence  of  early  symp- 


358  INJURIES   OF   THE    BRAIN   AND    MEMBRANES, 

toms  of  irritation ;  and  that  instances  are  not  infrequent  in 
which  these  fragments  constitute  not  only  the  most  immi- 
nent but  the  sole  source  of  danger.  They  make  it  no  less 
clear  that  the  bullet  may  rest  scarcely  below  the  cranial 
wall,  removable  by  the  simplest  possible  operative  means, 
but  left  undisturbed  as  surely  leading  on  to  death  as 
though  buried  deep  in  the  cerebral  substance.  They  can 
leave  no  question  that  the  continuance  of  removable  for- 
eign bodies  in  accessible  tissues,  the  neglect  to  provide  a 
channel  for  natural  drainage,  and  a  wilful  ignorance  of  the 
conditions  of  a  wound,  in  defiance  of  the  canons  of  surgi- 
cal law,  are  no  more  to  be  tolerated  here  than  in  other 
regions  where  the  proper  course  to  pursue  has  been  long 
unquestioned. 

The  incision  of  the  dura  mater  is  a  more  serious  pro- 
cedure than  exposing  and  enlarging  the  osseous  wound. 
There  are  instances  of  brain  implication  in  which  the  dura 
is  intact  or  has  suffered  no  more  than  trivial  injury ;  in  these 
some  natural  hesitation  in  resorting  to  deeper  explora- 
tion may  be  felt.  If  the  dura  mater  is  bulging  with  or 
without  pulsation,  or  is  bruised,  or  even  discolored,  the 
necessity  of  exposing  the  cerebral  surface  is  not  to  be 
doubted.  In  one  of  the  more  recently  reported  cases, 
dural  incision  gave  exit  to  a  small  amount  of  blood  and 
cerebral  debris,  and  was  followed  by  immediate  relief  of 
profound  coma  and  the  recovery  of  the  patient,  the  bullet 
having  been  previously  removed  from  the  external  wound. 
The  dura  mater  Avas  here  bulging,  though  apparently  unin- 
jured. In  another  case,  also  of  recent  date,  in  which  the 
bullet  was  impacted  in  the  cranial  wound,  the  uninjured 
dura,  which  maintained  its  normal  relation  to  the  subjacent 
cerebral  surface,  was  not  incised  and  death  ensued.     On 


SURGICAL    RELATIONS.  359 

necropsic  examination  a  small  superficial  clot  was  found 
in  the  midst  of  a  mass  of  softened  and  disintegrated  cere- 
bral tissue.  In  a  third  case,  the  inner  table  of  bone, 
though  not  apparently  broken  through,  was  fractured  and 
driven  back  into  the  cranial  cavity.  After  removal  of  the 
osseous  fragments,  the  dura  mater,  which  was  bulging  and 
had  been  slightly  wounded  by  a  spiculum  of  bone,  was,  evi- 
dently against  the  better  judgment  of  the  surgeon,  neither 
incised  nor  sutured.  A  week  later  death  resulted  from  an 
extensive  purulent  meningitis.  The  external  wound  had 
been  drained  and  aseptically  treated. 

These  instances  constitute  a  sufficient  argument  from 
experience  to  demonstrate  the  danger  which  may  lurk  be- 
hind a  dura  mater  which  the  bullet  has  left  untouched,  and 
which  can  be  estimated  and  possibly  surmounted  only  by 
inspection  of  the  parts  beneath.  If  the  appearance  of  the 
membrane  is  abnormal,  decision  should  be  no  less  easy 
than  action  prompt.  It  is  the  cases  in  which  the  dura 
mater  itself  affords  no  clew  which  occasion  doubt  and  hesi- 
tation. It  may  be  assumed  that  cortical  contusion  does 
not  often  exist  without  some  dural  indication ;  but,  as  this 
is  possible,  the  question  still  remains  whether  or  not  it  is 
safer  in  every  case  to  arrive  at  certainty.  When  the  bullet 
is  of  large  or  medium  calibre,  and  the  amount  of  cranial 
injury  indicates  much  force  of  impact,  the  probability  of 
cerebral  lesion  would  seem  not  only  to  justify  but  to  de- 
mand this  measure  of  prevention.  If  the  bullet  is  not  of 
larger  calibre  than  0.22,  the  inner  table  of  bone  not  com- 
minuted, and  the  dura  not  affected,  it  may  be  well  to  fore- 
go subdural  exploration.  In  any  case  in  which  doubt 
fairly  arises  preference  should  be  given  to  the  aggressive 
course,  and  with  adequate  aseptic  care  no  harm  will  come 


360  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

from  simple  exploration,  though  the  event  should  prove 
suspicion  to  have  been  unfounded. 

The  second  proposition  in  regard  to  the  proper  objects, 
demands,  and  limits  of  operative  treatment  recognizes  the 
necessity  of  superficial  exploration  and  removal  of  foreign 
bodies,  and  extends  similar  methods  to  deeper  parts  of  the 
brain  and  intracranial  cavity,  but  holds  their  utility  to 
exist  only  in  the  establishment  of  aseptic  conditions.  It 
denies  the  irritative  effect  of  foreign  bodies  in  the  brain 
tissue,  and  asserts  the  harmlessness  of  a  bullet  after  its 
lodgement  has  been  effected.  A  modified  view  admits  dan- 
ger from  its  retention,  but  regards  this  as  less  than  that 
which  attends  an  attempt  at  its  removal. 

As  this  proposition  involves  the  question  of  manage- 
ment of  the  bullet,  in  regard  to  which  there  has  been  not 
only  great  diversity  of  opinion  but  of  practice,  it  demands 
careful  scrutiny  in  the  light  of  experience  as  it  has  been 
disclosed  in  recent  years. 

First,  it  is  claimed  that  the  innocence  of  stranded  bul- 
lets has  been  established  by  the  subsequent  history  of  per- 
sons who  have  survived  the  immediate  effects  of  injury. 
There  have  been  forty-one  recorded  cases  in  the  series  of 
one  hundred  and  thirty-six,  the  greater  part  of  which,  in 
the  opinion  of  their  chroniclers,  may  be  placed  in  this 
category.  Of  these,  at  least  twenty-five  should  be  dis- 
carded as  of  questionable  character,  or  as  unverified  by  a 
sufficient  lapse  of  time.  In  four  of  the  twenty-five  the 
penetration  of  the  cranial  cavity  was  doubtful,  in  one  of 
which  in  fact  the  failure  was  demonstrated ;  in  a  second  the 
bullet  could  not  be  traced  through  the  orbital  wall ;  and 
in  a  third,  though  a  wound  of  the  occipital  lobe  was 
made   certain    by   the   presence  of   brain   matter   in   the 


SURGICAL   RELATIONS.  36 1 

hair,  the  absence  of  any  sort  of  primary  symptoms 
made  it  more  probable  that  the  missile  had  fallen  back 
and  escaped  externally  through  the  wound  of  entrance. 
The  fourth  case  is  that  of  a  man  who  is  said  to  have 
carried  in  his  brain  for  sixty-five  years  a  bullet  received 
at  the  battle  of  Waterloo.  There  is  no  medical  evi- 
dence that  the  cranial  cavity  was  penetrated,  no  necropsic 
examination  was  made,  and  no  S3'mptom  is  noted,  except 
"  a  feeling  at  the  back  and  lower  part  of  his  head,  such  as 
would  be  expected  to  arise  from  a  bullet  which  had  de- 
stroyed his  eye  and  traversed  the  brain  but  had  not  effected 
its  escape. "  To  those  who  have  not  experienced  this  "  feel- 
ing" the  corroboration  of  this  story  of  \Yaterloo  is  not 
entirely  sufficient  to  remove  it  from  the  doubtful  class. 

In  six  of  the  remaining  twenty-one  cases  the  final 
observation  was  made  within  one  month ;  in  ten  within 
six  months;  and  in  five  within  eight  to  eleven  months. 
In  some  of  them  at  such  time  there  were  no  s3^mptoms ; 
and  in  others  there  were  continued  indications,  more  or 
less  important,  of  cranial  injury. 

From  an  examination  of  the  sixteen  cases  which  remain 
from  the  forty-one,  though  in  some  instances  their  duration 
was  brief,  it  is  possible  to  derive  some  information  as  to 
the  alleged  innocuousness  of  the  bullet  when  retained  with- 
in the  cranial  cavity. 

(i)  Purulent  discharge  from  a  wound  of  the  left  parie- 
tal lobe,  which  continued  till  the  seventeenth  day,  when 
the  bullet  was  removed,  with  some  osseous  fragments, 
from  a  cavity  just  beneath  the  cerebral  cortex.  Subse- 
quent recovery. 

(2)  Wound  of  right  frontal  lobe,  which  healed.  Symp- 
toms of  mental  decadence  continued  till  death  on  the  thir- 


362  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

tieth  day.  Bullet  lodged  in  a  cavity  in  opposite  frontal 
lobe,  surrounded  by  clot  and  disintegrated  brain  tissue. 

(3)  Wound  of  right  parietal  lobe.  Death  on  the  thirty- 
sixth  day;  bullet  in  necrotic  tissue  beneath  median  sur- 
face of  same  lobe. 

{4)  Bullet  of  0.22  cal.  lodged  in  petrous  partion;  puru- 
lent discharge  till  death  from  sepsis  on  forty-first  day. 

(5)  Wound  of  left  frontal  lobe;  purulent  discharge 
from  wound  till  death  at  the  end  of  six  months.  Bullet 
found  post  mortem  with  osseous  fragments  in  a  superficial 
abscess  cavity. 

(6)  Wound  of  right  frontal  lobe;  purulent  discharge 
till  removal  of  bullet  from  just  within  the  osseous  wound 
in  the  seventh  month,  followed  by  hernia  cerebri  and- ulti- 
mate recovery. 

(7)  Wound  of  left  frontal  lobe ;  purulent  discharge  till 
death  at  a  period  not  stated.  Bullet  with  osseous  frag- 
ments found  in  a  superficial  abscess  cavity. 

(8)  Bullet  of  large  calibre,  lodged  in  an  undescribed  part 
of  the  brain,  caused  epileptic  convulsions  after  the  lapse  of 
several  months;  ceased  at  some  undefined  later  period. 

(9)  Both  frontal  lobes  traversed  by  a  bullet  of  0.22  cal. 
At  a  later  period  patient  became  irritable  and  quarrel- 
some. 

(10)  Mid-frontal  region  penetrated  by  a  bullet  of  0.22 
cal.  without  cerebral  injury.  No  symptoms  eighteen 
months  later. 

(11)  Wound  of  left  frontal  lobe  followed  by  epileptic 
convulsions,  which  continued  till  removal  of  osseous  frag- 
ments after  thirteen  months.  No  symptoms  six  months 
later,  except  improving  right  hemiplegia. 

(12)  Necropsy  in  case  of  a  demented  criminal  two  years 


SURGICAL    RELATIONS.  363 

after  injury.  Earlier  mental  condition  not  stated;  cere- 
bral convolutions  atropliied ;  bullet  encapsulated  upon  sur- 
face of  occipital  lobe ;  bullet  track  subdural  but  not  travers- 
ing the  brain. 

(13)  Wound  in  right  parietal  region;  brain  not  pene- 
trated ;  toy  pistol ;  four  years  later,  only  symptom  dilata- 
tion of  right  pupil. 

(14)  Wound  through  ear;  petrous  portion  fissured  at 
its  base ;  bullet  discharged  six  years  later  from  an  abscess 
in  the  throat. 

(15)  Wound  of  frontal  lobe  by  a  Minie  ball;  begin- 
ning of  epileptic  convulsions  at  the  end  of  fifteen  years, 
which  became  very  frequent  and  severe.  Bullet  then  re- 
moved from  just  within  cranial  cavity.  Entire  subsequent 
recovery. 

(16)  Wound  of  left  frontal  lobe;  bullet  of  0.22  cal. ; 
epileptic  convulsions  four  years  later,  becoming  frequent  at 
the  end  of  thirteen  years ;  trephination  and  removal  of  a 
fragment  of  bone  and  a  piece  of  lead;  convulsions  not  con- 
trolled. Death  one  year  later  from  cerebral  laceration,  the 
result  of  a  fall  during  a  paroxysm.  Bullet  found  in  left 
trunk  area,  projecting  through  the  cortex  near  the  median 
fissure  at  the  end  of  a  membranous  canal. 

There  are  other  cases  of  similar  import  in  which  recov- 
ery was  not  claimed. 

{a)  Bullet  of  small  calibre  made  entrance  through  the 
chin.  Death  twenty  days  later.  A  canal  extended  through 
left  frontal  lobe,  which  was  obstructed  by  reparative  prod- 
ucts ;  bullet  in  pus  cavity  at  its  farther  extremity. 

{b)  Bullet  traversed  both  hemispheres;  death  five 
months  afterward.  Bullet  then  found  resting  upon  the 
dura  mater  covering  the   basilar   process,    having    fallen 


364  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

downward  from  an  abscess  cavity  in  the  parietal  lobe,  at 
the  end  of  its  original  course. 

(f)  Wound  of  left  frontal  lobe  and  death  in  twentj'-two 
months;  bullet  and  osseous  fragments  contained  in  a  pus 
cavity  beneath  a  depressed  dural  cicatrix. 

{(i)  Wound  in  right  frontal  region  and  bullet  removed 
after  counter-trephination  from  abscess  cavity  in  occipital 
lobe  on  twentieth  da}- ;  death  ten  days  later. 

U)  Wound  in  mastoid  region :  unsuccessful  operation 
on  eleventh  day  after  pyaemic  chill;  bullet  found  post 
mortem  partly  within  lateral  sinus. 

In  twelve  cases  of  this  series  of  twenty-one  there  was 
sepsis  from  abscess  or  necrosis  of  the  cerebral  tissue  which 
was  directly  related  to  the  retention  of  foreign  bodies.  In 
two  the  nature  of  the  lesion  was  discovered  by  operation 
and  the  patient  recovered ;  in  ten  death  resulted,  usually 
at  an  early  period  and  without  attempt  at  operative  relief. 
In  three  of  the  fatalities,  and  in  one  of  the  recoveries,  the 
bullet  was  contained  in  a  superficial  abscess  cavity  and  was 
associated  with  osseous  fragments ;  in  seven  of  the  fatalities, 
and  in  one  of  the  recoveries,  the  cerebral  lesion,  whether 
abscess  or  simple  necrosis  of  tissue,  was  dependent  solely 
upon  the  presence  of  the  bullet,  which  with  one  exception 
was  at  a  distance  from  the  wound  of  entrance.  In  all, 
S3^mptoms  persisted  from  the  time  of  injury. 

In  another  group  of  four  cases,  though  the  bullet  re- 
mained in  the  cranial  cavity,  the  brain  was  uninjured  and 
there  were  no  symptoms  while  the  patient  continued  under 
observation,  a  period  of  from  one  and  one-half  to  six  years. 
In  the  one  instance  in  which  death  is  known  to  have  oc- 
curred later,  it  was  due  to  intercurrent  disease  two  years 
after  injury,  and  the  bullet  was  encapsulated. 


SURGICAL    RELATIONS.  365 

In  Still  another  group,  also  of  four  cases,  after  a  length- 
ened interval  in  which  no  symptoms  were  noted,  epilepsy 
occurred :  in  one,  after  several  months,  in  one  after  thir- 
teen months,  in  one  after  four  years,  and  in  the  last  after 
fifteen  years.  In  three  of  them  the  attacks  ceased:  in 
one  after  the  removal  of  the  bullet,  in  one  after  the  re- 
moval of  osseous  fragments,  and  in  one  without  operation. 
In  the  fourth  case  the  convulsions  continued  from  the 
fourth  to  the  fourteenth  year,  when  death  resulted  from 
accident. 

The  final  case  of  this  series  must  be  omitted  from  con- 
sideration, since  the  mental  disturbance  which  followed 
was  due  to  the  laceration  of  the  frontal  lobe  in  the  passage 
of  the  bullet  and  not  to  changes  at  the  point  of  lodge- 
ment. 

There  are  scattered  cases  of  earlier  date  in  which  life 
has  been  said  to  have  long  continued  despite  the  pres- 
ence of  a  bullet  in  the  brain.  These  histories  are  usually 
indefinite,  but  in  some  instances  it  seems  probable  that 
there  were  no  important  attendant  symptoms. 

It  is  evident  that  the  retained  bullet  has  proven  a 
menace  to  life  not  only  when  associated  with  osseous  frag- 
ments but  of  itself,  and  it  is  remarkable  that  an  opposite 
opinion,  supposed  to  be  founded  upon  actual  experience, 
should  have  become  prevalent.  There  is  probably  no 
authenticated  case  of  recent  Anglo-American  record  in 
which  a  bullet  left  in  the  brain  substance  has  failed  to 
work  mischief,  nor  has  the  evil  been  often  long  procras- 
tinated. There  have  been  occasional  instances  in  which  it 
has  remained  harmless  for  a  number  of  years  in  the  cranial 
cavity,  but  the  brain  has  not  been  penetrated.  The  fact 
that  epilepsy  has  developed  so  late  as  fifteen  years  after 


366  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

injury  must  make  even  apparently  exceptional  cases  doubt- 
ful. 

It  may  be  justly  concluded  from  these  actual  observa- 
tions, that: 

1.  The  bullet  left  by  necessity  or  choice  within  the 
cranial  cavity  is  usually  septic ;  and  necrotic  changes  ensue 
with  constitutional  infection. 

2.  The  bullet  when  aseptic  may  become  encysted  and 
may  then  be  harmless,  or,  more  probably,  may  be  the 
source  of  dural  or  cerebral  irritation  at  a  perhaps  distant 
period. 

Second :  it  has  been  thought  that  while  it  may  be  safer 
to  resort  to  operative  measures,  if  necessary,  for  the 
exploration  and  disinfection  of  the  superficial  cerebral 
wound,  the  peril  of  the  patient  is  augmented  rather  than 
diminished  by  an  effort  to  extract  the  bullet  from  deeper 
parts.  This  belief,  also,  has  been  credited  to  the  teach- 
ings of  experience. 

In  the  forty-nine  cases  which  constitute  the  sum  of  this 
experience,  as  it  has  been  made  known  in  English  and 
American  record  during  the  present  surgical  epoch,  death 
occurred  in  one  before  deep  exploration  had  been  begun, 
and  m  another  from  anaesthesia  before  the  beginning  of 
operation.  In  fifteen  cases  operation  was  confined  to  the 
cranial  wall  or  to  the  surface  of  the  brain.  There  remain 
thirty-two  cases  in  which  the  removal  of  the  bullet  from  a 
distant  point  of  lodgement  was  made  or  attempted.  Of  this 
number  of  cases,  eighteen  ended  in  recovery;  in  twelve  of 
which  measures  instituted  for  the  removal  of  the  bullet  suc- 
ceeded, and  in  six  failed.  In  fourteen  fatal  cases  removal 
was  effected  in  seven,  and  in  seven  failed.  In  the  nine- 
teen cases  in  which  the  removal  of  the  bullet  was  success- 


SURGICAL   RELATIONS.  367 

fully  accomplished,  it  was  withdrawn  from  the  wound  of 
entrance  in  but  three,  of  which  two  ended  in  recovery.  In 
sixteen  cases  in  which  it  was  removed  through  the  oposite 
cranial  wall,  counter-trephination  or  its  equivalent  Avas 
done  in  six  in  which  no  counter-fracture  existed,  twice 
with  recovery  and  four  times  w^ith  the  subsequent  death 
of  the  patient ;  in  three  other  cases,  all  ending  in  recovery, 
serious  operation  was  required ;  in  the  final  eight,  three  of 
which  were  fatal,  the  bullet  after  simple  external  incision 
was  removed  from  the  bone  or  cerebral  cortex.  In  the 
fourteen  cases  of  failure  to  discover  or  extract  the  bullet, 
recoveries  and  fatalities  were  in  equal  number. 

In  the  fourteen  cases  which  proved  fatal,  whether  or 
not  the  effort  to  remove  the  bullet  was  successful,  death 
was  due  to  septic  infection  in  eleven,  to  age  and  shock  of 
operation  in  two,  and  to  shock  alone  in  one.  The  salient 
points  in  their  histories  may  be  briefly  stated : 

(i)  Trephination  in  left  frontal  and  counter-trephina- 
tion in  right  parietal  region  on  the  first  day,  and  removal 
of  bullet  of  0.32  cal.  from  subcortical  tissue  after  incision 
of  the  dura  mater.  Death  twenty-four  hours  later  from 
shock,  due  to  age  and  unfavorable  conditions,  including 
extensive  cerebral  laceration  at  wound  of  entrance. 

(2)  Trephination  in  left  frontal  and  counter-trephina- 
tion in  left  occipital  region,  and  removal  of  bullet  of  0.22 
cal.  from  one  and  one-half  inches  below  point  of  counter- 
operation  ;  drainage  of  both  wounds,  followed  by  small 
fungus  cerebri  in  each  wound  with  other  symptoms 
of  cerebral  necrosis.  Death  in  twelve  days.  No  ne- 
cropsy. 

(3)  Counter-trephination  in  left  posterior  cranial  region 
twenty  days  after  a  wound  mflicted  through  right  malar 


368  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

bone,  and  removal  of  bullet  of  0.32  cal.  from  a  pus  cavity. 
Death  ten  days  after  operation. 

(4)  Trephination  in  left  frontal,  and  counter-trephina- 
tion  in  right  frontal  region  on  the  fourth  day;  bullet  not 
discovered ,  drainage  tube  through  the  brain.  Death  seven 
days  later;  purulent  meningitis,  and  left  frontal  diffuse 
abscess.      (Bullet  in  right  orbit.) 

(5)  Trephination  in  right  frontal  region  on  the  first 
day,  osseous  fragments  removed,  but  bullet  not  discov- 
ered.    Death  on  the  twelfth  day. 

Necropsic  conditions:  Pus  in  the  subcutaneous  cellular 
tissue;  purulent  meningitis,  and  cerebral  necrosis;  osse- 
ous fragments  found  in  the  brain  substance,  and  bullet  of 
less  than  0.22  cal.  lodged  in  the  right  frontal  lobe,  three 
inches  from  the  surface. 

(6)  Trephination  of  right  mastoid  on  the  eleventh  day; 
previous  pyaemic  chill.  Death  on  the  sixteenth  da}',  and 
bullet  of  0.22  cal.  found  partly  within  the  lateral  sinus. 

(7)  Trephination  in  the  right  frontal  region  on  the 
ninth  day;  large  cavity,  filled  with  blood  and  necrosed 
brain  tissue,  drained  ;  bullet  not  discovered.  Death  on  the 
fourteenth  day,  and  the  cavity  found  to  extend  to  the  oc- 
cipital lobe;  fragment  of  bullet  near  lateral  ventricle. 

(8)  Trephination  in  right  parietal  region  on  the  second 
day;  bullet  not  discovered.  Re-examination  in  another 
hospital  on  the  thirtieth  day;  external  wound  infected; 
large  cerebral  cavity  containing  necrotic  tissue  and  having 
firm  walls.  Death  on  the  thirty-sixth  day,  and  bullet 
found  to  have  been  deflected  by  falx  cerebri  one  inch 
backward  from  the  cavity  previously  recognized. 

(9)  Bullet  removed  from  right  petrous  portion  on  the 
fourth  day  by  finger  and  elevator  after  incision.     Death 


SURGICAL   RELATIONS.  369 

two   days   later;    fissure   found   in  petrous   portion;    pur- 
ulent meningitis. 

(10)  Incision  over  counter-fracture  in  posterior  tem- 
poral region  on  the  fourth,  day,  and  bullet  of  0.32  cal.  re- 
moved from  cerebral  cortex;  drainage  tube.  Death  on 
the  ninth  day ;  drainage  tube  found  to  contain  pus  and  its 
exterior  covered  with  necrotic  brain  tissue. 

(11)  Incision  over  counter- fracture  in  right  frontal 
region  and  removal  of  the  bullet  on  the  fourth  day. 
Death  in  fourteen  hours  from  "exhaustion." 

(12)  Removal  of  bullet  from  pharynx  on  the  second 
day;  the  patient,  aged  eighty,  then  unconscious,  with 
irregular  respiration.     Death  in  sixty  hours. 

(13)  Probing  to  depth  of  two  inches  on  the  eighth  day; 
pus  and  osseous  fragments  removed ;  bullet  not  discovered. 
Death  from  septic  infection  on  the  thirty-eighth  day.  No 
necropsy. 

(14)  Probing  deeply  through  right  frontal  lobe  on  the 
second  day;  bullet  not  discovered;  wound  of  entrance 
afterward  healed.  Death  on  the  thirtieth  day;  bullet 
found  surrounded  by  necrotic  tissue  in  the  left  island  of 
Reil. 

It  is  apparent  that  in  the  greater  part  of  these  fatalities 
interference  was  deferred  until  septic  changes  had  already 
occurred,  with  or  without  symptoms  of  general  infection. 
Operation  was  primary  in  but  three  cases,  and  in  four  of 
the  others  indications  of  the  constitutional  disorder  were 
already  manifest.  In  the  forty-two  deaths  which  occurred 
in  non-operative  cases,  inclusive  of  those  already  consid- 
ered in  relation  to  retention  of  the  bullet  and  osseous  frag- 
ments in  the  superficial  cerebral  wound,  and  exclusive  of 

the    ten    in  which  it  was  a  primary    result  of  shock  and 
24 


370  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

hemorrhage,  all  but  four  were  occasioned  by  septic  infec- 
tion following  a  local  lesion,  abscess,  meningitis,  or  cere- 
bral necrosis. 

The  ultimate  result,  therefore,  of  a  critical  analysis  of 
all  the  available  records  of  practical  experience,  the  court 
of  last  resort  in  matters  of  scientific  opinion,  is  that  the 
cause  of  death  has  been  ordinarily  the  same,  whether  or 
not  operative  interference  has  been  made;  and  that  the 
percentage  of  recovery  has  been  greater  when  operation 
has  been  performed.  If  allowance  were  made  for  the 
number  of  cases  in  which  sepsis  was  declared  prior  to 
operation,  or  in  which  other  antecedent  conditions  made 
interference  practically  hopeless,  the  statistical  advantage 
of  operation  would  become  very  decided. 

The  series  of  cases  collated  is  practically  complete  with- 
in its  limits  of  time  and  place.  It  has  not  included  reports 
of  cases  from  Continental  sources,  as  their  examination 
if  made  with  equal  care  would  have  entailed  an  almost 
impossible  amount  of  labor. 

The  statistical  results  which  have  been  obtained  have 
been  only  incidental  to  an  exact  determination  of  what 
have  been  the  real  teachings  of  experience.  Their  value 
in  this  relation  is  not  to  be  questioned ;  they  demonstrate 
the  accordance  of  the  facts  of  observation  with  general 
laws  of  surgery.  The  pathogenic  germs  are  not  less  prev- 
alent in  the  surroundings  and  instrumentalities  of  treat- 
ment of  cerebral  wounds  than  elsewhere,  and  it  would  be 
inconceivable  that  their  preventive  control  or  destruction 
should  be  less  indispensable. 

The  propriety  of  operation  having  been  established,  its 
methods  and  limitations,  and  the  details  of  treatment,  are 
still  to  be  considered. 


SURGICAL   RELATIONS.  37 1 

When  the  general  condition  of  the  patient  has  so  far 
improved  that  it  has  ceased  to  occasion  immediate  anxiety, 
the  superficial  and  osseous  wounds  should  receive  more 
thorough  attention.  The  surface  should  be  cleansed  and 
shaven,  and  search  should  be  made  for  embedded  grains 
of  powder  or  remaining,  traces  of  smoke  and  flame,  the 
cutaneous  wound  enlarged  by  incision,  the  extent  of  sub- 
cutaneous lesion  determined,  and  the  superficial  soft  parts 
made  surgically  clean.  If  there  has  been  large  comminu- 
tion, the  fragments  of  bone  may  require  elevation,  though  in 
such  cases  the  subjects  rarely  survive  the  immediate  shock 
of  injury.  If,  as  is  more  probable,  the  fracture  has  been  a 
simple  perforation  with  possibly  a  fine  marginal  comminu- 
tion, the  osseous  wound  should  be  adequately  enlarged  by 
the  rongeur,  the  dura  incised,  and  whatever  small  detached 
fragments  and  foreign  substances  can  be  detected  removed 
from  the  accessible  part  of  the  cerebral  laceration.  In 
those  cases  in  which  the  bullet  has  made  exit,  the  second 
wound  in  its  superficial  and  deeper  portions  is  to  be  pri- 
marily treated  like  the  wound  of  entrance,  and  both 
wounds  are  to  be  closed  with  the  usual  aseptic  precautions. 
It  may  happen  that  the  bullet  is  lodged  just  within  the 
cranial  wound  of  entrance,  or  of  exit,  and  may  be  readily 
removable.  This  fact  is  to  be  borne  in  mind  in  the  pre- 
liminary examination. 

The  necessity  of  securing  and  maintaining  the  most 
perfect  attainable  asepsis  is  so  well  recognized  as  the  in- 
exorable law  in  all  surgical  procedures  that  it  may  be 
assumed  to  be  enforced  in  wh'atever  dressings,  explora- 
tions, or  operative  interferences  may  be  deemed  proper, 
though  its  specific  mention  may  be  sometimes  omitted. 

It  is  at  this  point  that  differences  of  opinion  have  led  to 


372  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

differences  in  practice.  These  affect  not  only  the  attempt 
at  removal  of  the  bullet  and  foreign  substances  from 
deeper  parts  through  the  wound  of  entrance,  and  the  re- 
sort to  counter-trephination,  but  also  the  use  of  the  probe 
and  the  extent  to  which  mechanical  drainage  may  be  em- 
ployed. The  obligation  of  exploration,  and  of  operation 
if  practicable,  can  no  longer  be  evaded  when  answerable 
conditions  exist  in  the  individual  case.  The  analytic 
study  of  the  results  obtained  in  actual  practice,  and  the 
disclosures  of  necropsic  examination,  leave  no  justification, 
and  the  authority  of  the  general  principles  of  surgery 
affords  no  warrant,  for  inaction.  The  opinion  that  the 
bullet  is  harmless  while  at  rest,  or  if  not  harmless  is  less 
harmful  than  the  effort  to  determine  its  position  or  to 
effect  its  removal,  is  disproved  by  the  experience  from 
which  it  claims  to  be  derived.  The  evidence  is  conclusive 
that  bullets  when  retained  in  the  brain,  even  though  en- 
capsulated or  unproductive  of  symptoms  for  a  length  of 
time,  eventually  lead  to  death,  while  their  removal  not 
infrequently  permits  recovery.  The  baneful  influence 
exerted  by  osseous  fragments,  when  left  in  contact  with 
the  dura  mater  or  embedded  in  the  cerebral  substance,  is 
even  less  likely  than  that  of  the  bullet  to  be  delayed  by 
encapsulation  or  by  the  exceptional  tolerance  of  a  sensitive 
tissue;  and  the  imperative  necessity  for  their  removal  is 
even  less  an  admissible  question,  as  the  record  of  cases  has 
made  evident. 

An  exaggerated  estimate  of  the  danger  of  necessary 
and  reasonably  skilful  mechanical  treatment  of  brain 
wounds  was  naturally  made  in  the  early  days  of  aseptic 
methods  before  the  mental  focus  had  been  adjusted  to  new 
conditions,  and  while  men's  minds  were  still  dominated 


SURGICAL    RELATIONS.  373 

by  their  earlier  experience.  It  is  more  difficult  to  com- 
prehend how  it  should  prevail  to  some  extent  at  the  pres- 
ent time,  when  greater  familiarity  with  aseptic  laws  has 
brought  a  juster  appreciation  of  the  widened  limits  within 
which  surgical  interference  may  still  be  conservative. 
The  imminent  danger  of  sepsis  which  once  attended  oper- 
ative invasions  of  the  great  cavities  of  the  body  has  been 
precluded,  or  at  least  made  possible  only  by  neglect;  the 
real  source  of  this  danger  is  from  within,  where  it  is  abso- 
lute, and  not  from  without,  where  it  is  only  contingent. 
The  peculiar  peril  of  such  operations  arises  from  the  oc- 
currence of  shock,  when  they  are  too  extensive,  too  san- 
guinary, or  too  much  prolonged.  The  brain  tissue  is  not 
especially  tolerant  of  mechanical  injury,  but  the  procedures 
taken  to  discover  or  extract  a  bullet  need  never  be  made  a 
test  of  its  endurance.  The  proper  use  of  the  probe  is 
confined  to  the  existent  wound,  so  that  contact  is  made 
only  with  already  disintegrated  tissue  which  is  no  longer 
capable  of  irritation ;  the  penetration  of  adjacent  uninjured 
parts  is  not  contemplated  and  is  indefensible.  This  with- 
drawal of  a  foreign  body  from  along  the  track  which  it  has 
followed  will,  if  it  be  deeply  situated,  probably  involve 
additional  laceration.  The  extent  of  visceral  injury  nec- 
essary to  the  extirpation  of  a  clearly  diagnosticated  and 
accessible  brain  tumor  of  moderate  size  has  not  prevented 
its  acceptance  as  a  justifiable  operation  in  surgery.  The 
bullet,  rendered  accessible  by  the  wound  which  it  has  made 
and  traversed,  its  situation  clearly  defined  by  the  probe, 
its  size  necessarily  small  but  its  capacity  for  mischief  un- 
limited, can  be  ordinarily  extracted  with  less  injury  or 
destruction  of  tissue,  and  with  less  hemorrhage  or  expen- 
diture of  time,  than  the  smallest  conceivable  tumor.     The 


374  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

simple  fact  that  some  additional  brain  laceration  must  be 
involved  in  the  withdrawal  of  a  bullet  is  evidently  insuffi- 
cient reason  to  forbid  the  attempt,  though  its  probable 
extent  may  be  a  sufficient  contraindication  in  individual 
cases.  The  possible  capacity  or  technical  skill  of  the  sur- 
geon cannot  be  ignored  in  such  a  review  of  the  subject, 
but  its  adequacy  must  be  assumed  in  a  general  discussion 
of  surgical  propriet)'. 

In  view  of  these  several  facts  and  inferences,  it  may  be 
regarded  as  established  that  if  the  bullet  remains  within 
the  cranial  cavity  an  effort  should  be  made  to  determine 
its  location,  and  if  detected  that  the  advisability  of  an 
attempt  to  effect  its  removal  should  at  once  be  brought  in 
question.  It  may  be  so  readily  approachable,  and  its  re- 
moval so  evidently  practicable,  as  to  leave  no  room  for 
hesitation ;  or  its  situation  may  be  so  uncertain  or  so  inac- 
cessible that  to  attempt  operation,  or  to  refrain,  may  seem 
fraught  with  equal  danger,  and  the  decision  will  then  re- 
quire the  exercise  of  great  discretion  as  well  as  of  careful 
and  perhaps  prolonged  examination.  The  advantage  of 
the  earliest  possible  interference,  in  view  of  the  patient's 
general  condition,  if  it  is  to  be  made  at  all,  is  as  positive 
here  as  it  is  in  amputation  for  trauma  involving  the  ex- 
tremities. The  comparative  tolerance  exhibited  by  the 
recently  wounded  brain  to  further  injury  by  operation 
should  be  given  much  weight  as  an  element  in  the  consid- 
eration of  all  very  recent  cases  in  which  doubt  exists  in  de- 
ciding upon  a  policy  of  action  or  inaction.  The  imminence 
of  septic  infection  from  the  earliest  moment,  and  in  its 
face  the  probable  futility  of  a  deferred  operation,  are  still 
more  potent  reasons  for  quickness  of  decision  and  for 
promptitude  in  whatever  action  is  to  be  taken.     The  data 


SURGICAL    RELATIONS.  375 

and  conclusions  of  writers  of  a  somewhat  earlier  period 
are  no  longer  of  authority.  The  fact  that  the  missile  of 
which  they  wrote  was  the  musket  or  rifle  and  not  the 
pistol  ball,  is  perhaps  of  no  great  importance,  nor  even  the 
changes  which  have  been  made  in  its  weight,  form,  and 
velocit}'',  if  lodgement  has  been  once  effected;  but  the 
methods  of  surgery  have  so  radically  changed  with  more 
exact  knowledge  of  pathology  that  the  propriety  of  opera- 
tions generally  must  be  reconsidered  and  new  rules  of  pro- 
cedure formulated. 

The  first  step  in  the  attempted  removal  of  the  bullet, 
the  exploration  of  the  cerebral  wound  with  a  view  to  local- 
ization, is  not  only  a  diagnostic  method  but  an  incident  of 
treatment.  The  necessity  of  some  explorative  invasion  of 
the  cranial  cavity  is  always  involved ;  for,  even  though  the 
bullet  rest  in  the  external  wound,  more  dangerous  osseous 
fragments  may  yet  lurk  beneath  the  cranial  opening.  The 
extent  to  which  it  may  be  properly  carried  and  the  manner 
of  its  pursuance  still  require  consideration.  The  funda- 
mental law  which  should  govern  the  surgeon  in  his  choice 
and  use  of  the  means  of  exploration  is  that  the  least  pos- 
sible additional  laceration,  compatible  with  the  attainment 
of  the  information  sought,  should  be  inflicted.  It  is  desir- 
able that  a  single  instrument  should  be  selected,  preferabl)' 
that  of  Fluhrer  or  of  Girdner  as  best  suited  to  the  purpose, 
and  that  no  substitution  of  one  instrument  for  another 
should  be  subsequently  made  except  for  sufficient  and 
well-defined  reason.  If  the  probe  first  employed  should 
have  a  bulb  too  large,  or  be  otherwise  unsuited  to  follow 
the  path  which  the  bullet  has  opened,  it  should  at  least 
indicate  with  precision  the  character  of  the  one  which 
should  take  its  place.     The  utmost  caution  should  be  ex- 


3/6  INJURIES    OF    THE    BRAIN   AND    MEMBRANES. 

ercised  to  keep  within  the  wound,  since  false  passages  are 
as  readily  made  and,  when  made,  as  embarrassing  to  fur- 
ther exploration  as  those  which  follow  the  reckless  use  of 
the  urethral  sound.  It  has  been  held  that  when  the  probe 
ceases  to  advance  without  the  exercise  of  force,  the  limit 
of  persistence  has  been  reached.  This  is  approximately 
rather  than  exactly  true.  The  probe  does  not  fall  by  its 
own  weight  into  the  depths  of  the  cerebral  wound.  The 
channel  which  the  bullet  has  left  behind  it  is  not  likely  to 
be  open,  but  filled  with  coagula  and  disintegrated  tissue, 
and  some  force,  gentle  as  it  may  be,  is  required  to  pene- 
trate this  pulpy  mass,  and  some  manipulation  alone  can 
guide  the  instrument  past  obstructing  osseous  fragments 
or  through  an  intracerebral  dural  opening.  The  judg- 
ment of  the  surgeon  must  decide  what  measure  of  force  is 
excessive,  as  the  acuteness  of  his  perception  must  indicate 
when  the  bulb  impinges  upon  the  denser  but  still  tender 
wall  of  normal  structure.  The  work  of  exploration  may 
be  tedious,  but  time  is  of  minor  importance,  while  caution 
is  imperative. 

The  bullet,  if  not  at  once  deflected,  ordinarily  holds  a 
straight  course  into  the  opposite  hemisphere ;  it  is  better, 
therefore,  if  the  track  can  be  followed  deeply  but  without 
result,  to  resume  the  search  from  the  opposite  cerebral 
surface.  If  the  track  be  lost  near  its  outset,  the  osseous 
wound  should  be  further  enlarged  and  the  brain  incised  to 
reach  and  follow  its  new  departure.  The  manipulation  of 
the  probe  should  be  not  only  gentle  and  cautious  but 
always  directed  by  a  settled  purpose,  and,  this  accom- 
plished, should  be  at  once  abandoned.  When  the  surgeon, 
disappointed  and  impatient  at  failure  in  his  quest,  thrusts 
the  instrument  into  the  brain  recklessly  and  at  random, 


SURGICAL    RELATIONS.  377 

or  nervously  again  and  again  explores  a  channel  which  the 
first  examination  shows  to  lead  to  nothing  tangible,  in  the 
hope  that  some  chance  may  disclose  to  him  what  his  intel- 
ligence has  been  unable  to  discover,  no  good  and  much 
harm  may  come  from  it.  Every  misdirected  or  superflu- 
ous insertion  of  this  small  instrument  may  increase  al- 
ready dangerous  laceration  and  hemorrhage,  and  invite 
already  imminent  necrosis  of  tissue  and  subsequent  gen- 
eral sepsis.  These  rules  of  conduct  in  the  employment  of 
the  probe  are  simple,  and  may  seem  too  obvious  for  much 
insistence,  but  their  neglect  and  its  known  results  have 
excited  a  popular  prejudice  against  its  proper  and  neces- 
sary use,  which  has  in  turn  sometimes  engendered  too 
much  timidity  on  the  part  of  the  surgeon.  The  instru- 
ment first  chosen,  if  unfit  or  if  it  has  served  its  pur- 
pose, should  be  unhesitatingly  changed ;  investigation 
should  be  thorough,  but  nothing  should  be  done  with- 
out reason ;  force  should  never  take  the  place  of  art, 
and  no  dependence  should  be  had  upon  the  aid  of 
accident. 

If  the  bullet  cannot  be  detected  by  the  probe,  there 
may  be  circumstances  which  invite  the  use  of  the  needle. 
A  resistance  may  be  felt  which  the  blunt  instrument  fails 
directly  to  reach ;  there  may  be  reason  to  believe  that  the 
missile  lies  near  the  cerebral  surface  while  an  angle  in  its 
track  prevents  direct  pursuit  without  incision ;  a  deeper 
wound  may  be  too  tortuous  to  follow ;  or  localizing  symp- 
toms may  have  been  developed ;  any  one  of  which  condi- 
tions might  justify  this  resort.  The  wound  made  is  so 
minute  that  hemorrhage  is  inconsiderable,  and  laceration 
can  be  scarcely  said  to  be  produced.  The  experience 
gained  in  the  use  of  this  sort  of  puncture  in  cerebral  oper- 


378  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

ations  which  have  not  been  necessitated  by  traumatism 
confirms  its  comparative  if  not  absolute  safety.  There 
may  be  other  indications  which  the  exigencies  of  a  case 
will  suggest,  but,  while  even  occasional  instances  of  fatality 
from  this  seemingly  harmless  method  of  investigation  are 
recorded,  its  purely  empirical  employment  should  not  be 
recommended. 

In  those  cases  in  which  from  shortness  of  range  or  pro- 
fuseness  of  hemorrhage,  or  at  a  later  period  from  neglect, 
there  may  be  much  laceration  or  disintegration  of  brain 
substance,  the  finger  may  well  supersede  any  other  me- 
dium of  exploration.  It  is  more  sensitive  than  metal  and 
is  in  immediate  in  place  of  indirect  communication  with 
the  guiding  intelligence,  and,  as  room  is  already  provided 
without  new  destruction  of  tissue,  there  is  nothing  to 
counterbalance  the  positive  advantage  which  it  offers. 
This  gives  no  warrant,  however,  for  its  introduction  in  or- 
dinary cases  in  which  the  track  is  comparatively  narrow, 
and  in  which  the  violent  invasion  of  an  organic  structure 
heretofore  intact  must  necessarily  add  a  new  element  of 
danger. 

There  are  exceptional  cases  in  which  there  may  be 
sufficient  reason  to  believe  that  the  bullet  has  escaped  from 
the  cranial  cavity  to  justify  an  abandonment  of  cerebral 
search,  even  though  the  point  of  exit  may  not  be  discerni- 
ble. Its  course  may  be  so  manifestly  toward  the  orbit,  or 
subbasic  or  suboccipital  region,  that,  in  the  absence  of 
serious  cerebral  symptoms  and  after  fruitless  exploration 
of  the  cerebral  wound,  it  may  be  judicious  to  assume  this 
extracranial  lodgement  and  to  await  the  possible  develop- 
ment of  local  confirmatory  symptoms.  It  may  even  hap- 
pen, as  in  several  of  the  accompanying  series    of    cases, 


SURGICAL   RELATIONS.  379 

that  the  osseous  exit  into  the  base  or  orbit  may  be  dis- 
covered. 

The  bullet  having  been  recognized  in  an  accessible 
region  of  the  brain,  the  same  care,  gentleness,  and  avoid- 
ance of  cerebral  laceration  which  are  essential  in  the  de- 
termination of  its  position  should  be  observed  in  the  use 
of  instruments  for  its  removal.  The  particular  instrument 
employed,  if  adapted  to  its  purpose,  is  of  less  importance 
than  the  manner  of  its  use.  The  operation  is  often  diffi- 
cult and  may  be  sometimes  judiciously  abandoned;  the 
bullet,  already  deeply  situated,  may  with  every  effort  at 
extraction  sink  deeper  into  the  yielding  tissue  in  which  it 
is  embedded  and  in  a  direction  inaccessible  for  counter- 
operation,  or  until  its  removal,  if  finally  accomplished, 
would  involve  lesion  of  the  brain  substance  so  extensive 
as  to  entail  greater  danger  than  would  result  from  leaving 
it  undisturbed.  If  pursuit  be  abandoned  from  the  rear, 
there  remains  the  resort  of  attacking  it  from  in  front. 
The  bullet  may  have  originally  occupied,  or  been  forced 
into,  a  position  in  which  it  is  in  evident  close  contiguity  to 
the  superior  orbital  plate.  If  the  effort  to  withdraw  it 
through  the  wound  of  entrance  seems  hopeless  without  too 
greatly  destructive  laceration  of  brain  structure,  success 
may  attend  approach  through  the  orbit.  An  incision  may 
be  made  which  will  permit  the  enucleation  of  the  eye  and 
its  appendages  en  masse,  and  their  replacement  without 
subsequent  deformity  or  injury  to  vision.  The  bullet  is 
then  reached  through  the  orbital  wall  at  the  point  indi- 
cated by  the  probe  passed  through  the  cerebral  wound. 
The  same  method  is  applicable  when  the  original  lodgement 
of  the  bullet  is  effected  within  the  orbit.  If  vision  has 
been   destroyed  by  intracranial   or  orbital   injury,    or  by 


380  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

lesion  of  the  optic  nerve  as  it  passes  through  the  optic 
foramen,  operation  will  be  simplified  by  the  necessary 
removal  of  the  eye. 

The  equivalent  of  the  operation  through  the  orbital 
plate  is  found  in  counter-trephination  through  the  opposite 
wall  of  the  calvarium  which  has  remained  intact.  It  is 
indicated  in  a  case  in  which  the  bullet  has  been  discovered 
deep  in  the  substance  of  the  brain,  perhaps  across  the 
median  line,  the  attempt  to  withdraw  it  having  been  fore- 
gone as  fruitless  or  desperate  and  with  no  hope  of  reach- 
ing it  through  the  orbit;  or  when,  the  bullet  having  been 
traced  far  inward,  its  track  has  been  utterly  lost,  and  no 
clew  exists  to  its  place  of  lodgement.  There  is  no  alterna- 
tive, except  the  chance  of  recovery  with  the  bullet  left  un- 
disturbed or  this  single  operative  resort.  It  is  a  dilemma 
in  which  inaction,  the  easier  course,  seems  to  have  been 
the  oftener  chosen  in  the  few  instances  in  which,  as  it 
would  seem,  such  an  operation  might  have  been  undertaken 
with  fair  prospect  of  success.  The  early  successful  cases 
of  Larry  and  Charles  Bell  are  familiar.  In  recent  years 
but  five  others  have  been  recorded,  of  which  four  proved 
fatal.  Fluhrer's  case  in  1884,  followed  by  recovery,  has  at- 
tracted much  and  deserved  attention.  The  bullet  of  0.22 
cal.  penetrated  the  mid-frontal  region,  and  was  followed  by 
the  probe  for  six  inches  through  the  left  frontal  lobe  and 
falx  cerebri  into  the  opposite  hemisphere.  The  cranial  wall 
on  the  right  side  was  trephined  three-fourths  of  an  inch  be- 
low the  point  at  which  the  instrument  if  projected  would 
emerge,  and  the  dura  was  incised.  Following  a  trail  of  blood 
and  later  of  brain  matter,  the  bone  was  cut  away  and  the 
dura  further  incised  till  a  wound  in  thepia  was  discovered, 
through  which  the  bullet  was  removed  from  one-half  inch 


SURGICAL   RELATIONS.  38 1 

below  the  cerebral  surface.  The  only  reported  case  of  re- 
moval of  the  bullet  frora  the  brain  through  the  orbital  wall, 
Case  CCXCIV.  in  the  accompanying  series,  is  practically  of 
the  same  character,  though  the  chisel  was  used  in  place  of 
the  trephine.  Operation  was  done  on  the  second  day,  with 
a  rectal  temperature  of  104°.  The  wound  of  entrance  in  the 
right  temporal  fossa  was  enlarged  by  the  trephine,  frag- 
ments of  bone  were  removed,  and  the  bullet  was  discovered 
near  the  optic  foramen.  The  eye,  which  was  distended 
with  blood,  was  removed  ;  the  superior  orbital  plate,  which 
was  much  comminuted  by  fissures,  but  not  broken  through, 
was  perforated  by  the  chisel;  the  dura  was  incised,  and  the 
bullet  removed  from  the  cerebral  cortex.  The  patient 
eventually  recovered.  The  necropsic  examinations  included 
in  the  series  of  published  cases  disclose  occasional  instances 
in  which  the  directness  of  the  bullet's  course,  and  its  lodge- 
ment near  the  cerebral  surface  in  an  accessible  region, 
would  have  made  such  operations  anatomically  possible, 
and  which  the  histories  show  would  have  been  clinically 
proper.  Their  number,  after  an  eliminative  process  by 
death  before  reaction,  by  extraction  of  the  bullet  through 
the  wound  of  entrance,  or  by  an  obvious  impropriety  of 
further  interference,  is  necessarily  very  limited. 

The  justification  of  counter-operation  through  the  un- 
injured cranial  wall  in  properly  selected  cases  is  based 
upon  the  same  considerations  which  justify  the  use  of  the 
probe  for  localization  and,  under  suitable  conditions,  the 
effort  to  withdraw  the  bullet  through  the  original  wound. 
The  avoidance  of  sepsis,  and  the  conduct  of  operation  in 
such  manner  as  to  limit  shock,  are  no  less  under  the  con- 
trol of  the  surgeon,  but,  as  additional  and  more  considera- 
ble injury  is  to  be  inflicted  upon  the  brain,  still  greater 


382  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

caution,  if  not  more  conservatism,  in  estimating  the  rela- 
tive danger  of  an  aggressive  and  of  an  expectant  policy 
will  be  required. 

The  circumstances  adverse  to  this  operation  are :  First, 
a  bad  general  condition  of  the  patient  succeeding  primary 
shock,  a  high  temperature,  a  feeble  and  frequent  pulse, 
and  other  indications  of  an  inability  to  sustain  the  shock 
of  further  cerebral  injury ;  second,  extensive  cerebral  lac- 
eration about  the  wound  of  entrance  from  the  explosive 
effect  of  a  large  bullet  at  close  range,  or  a  suggestion  of 
wide  destruction  in  its  track  from  the  severity  and  diver- 
sity of  localizing  symptoms;  third,  great  uncertainty  as  to 
the  course  of  the  ball,  or  its  direction  toward  an  inaccessi- 
ble cranial  region;  fourth,  the  fact  that  its  course  has  in- 
volved the  base  of  the  brain;  and  fifth,  the  bullet  having 
been  of  0.22  cal.  or  less.  The  fact  that  the  bullet  has 
taken  its  course  upon  or  near  the  basilar  surface  is  to  be 
regarded  as  a  contraindication,  because  it  is  more  than 
likely  to  be  deflected  near  the  median  line  into  a  central 
region  of  the  brain  by  resistance  offered  by  some  part  of 
the  ethmoid  or  sphenoid,  or  by  the  basilar  process  of  the 
occipital  bone.  The  fact  that  the  bullet  is  of  0.22  cal.  or 
less  is  a  contraindication,  because  its  course  is  usually 
erratic  and  its  track  minute,  and  because  its  momentum  is 
so  comparatively  slight  that  it  rarely  reaches  an  accessible 
part  of  the  opposite  cerebrum.  No  one  of  these  contra- 
indications of  course  is  an  absolute  bar  to  operation.  If, 
on  the  contrary,  the  constitutional  condition  is  good  and 
the  laceration  is  confined  to  a  narrow  track,  if  a  bullet  of 
0.32  cal.  or  larger  has  been  driven  through  the  central  or 
upper  regions  of  the  brain  toward  some  part  of  the  vault, 
if  its  track   can  be  traced  deep  into  the  opposite  hemi- 


SURGICAL    RELATIONS.  383 

Sphere,  and  more  especially  if  the  patient  has  the  advan- 
tage of  youth,  it  will  be  judicious,  after  the  exhaustion  of 
other  means,  to  resort  to  this  ultimate  method  of  relief. 

If  the  counter-operation  be  resolved  upon,  it  is  well  to 
regard  it  in  the  first  instance  as  simply  explorative.  The 
cerebral  surface  having  been  exposed,  and  the  area  of  ex- 
posure having  been  increased  at  discretion  without  per- 
ceptible evidence  of  lesion,  the  operation  may  be  properly 
terminated  at  this  point,  unless  the  bullet  can  be  discov- 
ered by  palpation,  or  unless  its  position  has  been  ascer- 
tained by  the  exploration  of  the  original  wound  to  be  of 
easy  access  through  the  new  incision.  This  amount  of  ad- 
ditional or  secondary  injury,  confined  essentially  to  the  scalp 
and  cranium,  can  be  inflicted  with  almost  absolute  safety, 
provided  sufficient  care  is  taken  to  control  hemorrhage.  If, 
however,  a  trail  of  blood  or  of  particles  of  brain  matter  can 
be  traced  to  a  wound  in  the  cerebral  cortex,  or  if  the  color 
and  consistency  of  the  surface  indicate  subjacent  lacera- 
tion, the  operation  should  be  continued  with  a  view  to 
extraction  of  the  bullet,  and  no  harm  can  come  from  inci- 
sion of  the  already  lacerated  tissue.  If  the  patient  be  en- 
feebled by  age  or  be  in  ill  condition,  and  much  blood  be 
lost  in  the  incisions  of  the  scalp  and  dura,  or  if  the  unin- 
jured brain  be  too  freely  wounded  in  exploration,  the 
operation  may  readily  lead  to  disaster. 

Such  methods  of  treatment  as  have  been  outlined  are 
in  consonance  with  present  views  of  the  proper  utilization 
of  the  surgical  resources  at  command  for  the  management 
of  lesions  of  the  great  cavities.  Ideas  are  no  less  conser- 
vative than  formerly,  but  conservatism  is  more  intelligent. 
Ten  years  and  more  ago  it  was  the  fashion  to  abstain  from 
interference  with  gunshot  wounds  of  the  brain,  to  the  ex- 


384  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

tent  of  leaving  the  bullet  or  fragments  of  bone  at  the  very 
entrance  of  the  cerebral  track  or  even  beneath  the  skin  at 
the  point  of  exit.  It  was  considered  proper  to  depend 
wholly  upon  aseptic  treatment  as  represented  by  covering 
the  external  wound  with  a  single  layer  of  carbolized  lint. 
The  principles  of  asepsis  were  recognized,  but  their  appli- 
cations were  primitive  and  inefficient,  and  the  journals  of 
the  period  contain  many  histories  of  this  kind  with  an- 
swerable results  of  septic  inflammation  and  death.  It  is 
characteristic  of  the  present  epoch  to  employ  available  in- 
strumentalities to  their  full  extent,  and  to  pursue  to  a 
logical  and  practical  result  whatever  advantage  they  may 
offer.  The  later  consideration  of  prognosis  as  affected  by 
the  removal  or  retention  of  the  bullet  will  demonstrate  the 
conservatism  of  what  under  imperfectly  appreciated  con- 
ditions were  regarded  as  radical  measures. 

The  final  point  in  treatment,  in  regard  to  which  differ- 
ence of  opinion  may  exist,  concerns  the  methods  of  disin- 
fection and  drainage  of  the  cerebral  wound.  The  bullet, 
whether  it  has  pierced  the  opposite  cranial  wall,  or  been 
removed  by  counter-trephination,  or  has  been  withdrawn 
through  the  track  by  which  it  entered,  has  necessarily  left 
an  area  of  disintegrated  and  dead  tissue  which  may  become 
the  source  of  subsequent  general  infection.  This  danger, 
which  was  noted  as  attendant  upon  cases  of  ordinary  brain 
laceration  without  external  injury,  is,  of  course,  more  im- 
minent in  gunshot  cases,  in  which  sepsis  is  not  only  possi- 
ble from  original  contamination  by  foreign  substances,  but 
from  continued  exposure  to  atmospheric  influences.  The 
advantage  to  be  derived  from  drainage  and  disinfection  is 
beyond  question;  the  extent  to  which  it  maybe  justifia- 
ble or  profitable  to  subject  the  brain  tissues  to  mechanical 


SURGICAL   RELATIONS.  385 

interference  in  the  pursuit  of  these  objects  is  still  a  matter 
of  somewhat  varied  opinion  and  practice.  It  must  not  be 
forgotten  that  the  brain  is  permeable  to  fluids,  and  that 
less  sensitive  structures  suffer  from  the  irritation  of  drain- 
age tubes  when  too  freely  used  or  too  long  continued  in 
the  wound.  The  irrigation  of  the  brain  and  the  insertion 
of  drainage  tubes  into  and  through  its  substance  should 
be  practised  with  great  reserve,  lest  their  good  results  be 
more  than  counterbalanced  by  the  structural  injury  which 
they  inflict.  The  cases  in  which  neither  bullet  nor  other 
foreign  body  has  been  found  in  the  deeper  wound,  and  in 
which  the  track  is  narrow,  will  be  more  safely  treated  if 
aseptic  fluids  are  confined  to  the  external  parts  and  to  the 
cerebral  cortex,  and  the  removal  of  the  more  inaccessible 
coagula  and  debris  of  tissue  is  trusted  to  absorption  and 
natural  drainage.  The  other  cases,  in  which  greater  and 
more  widespread  damage  has  been  done  to  the  central 
regions  of  the  brain  by  the  extraction  of  the  bullet  or  of 
large  fragments  of  bone,  or  by  complete  perforation  by 
missiles  of  large  calibre,  demand  more  active  interference. 
In  the  irrigation  which  may  then  become  advisable  the 
prompt  return  of  the  antiseptic  fluid  should  be  insured  by 
a  dependent  position  of  the  external  wound,  by  the  use  of 
a  double  catheter  or  by  other  adequate  means,  and  its 
flow  should  not  be  unnecessarily  profuse.  The  drainage 
tube,  if  used  at  all,  should  be  withdrawn  and  abandoned  at 
a  very  early  period,  usually  on  the  second  day.  If  drain- 
age is  to  be  maintained  for  a  longer  time,  horsehairs  or 
threads  of  chromicized  catgut  may  replace  the  tube,  and 
their  number  be  reduced  from  day  to  day.  Certain  ob- 
jections made  to  the  drainage  tube  by  Hunt  in  the 
Australasian-Intercolonial   Medical    Congress  of    1892  are 


386  INJURIES   OF   THE    BRAIN    AND    MEMBRANES. 

worthy  of  especial  consideration  in  relation  to  deep  cere- 
bral wounds: 

(i)  That  it  is  an  irritant  foreign  body. 

(2)  That  it  is  likely  to  become  filled  with  clot,  and 
then  act  as  a  plug  rather  than  as  a  drain. 

(3)  That  it  is  a  medium  for  the  deep  implantation  of 
septic  elements  when  the  surface  has  become  infected. 

If  the  preparation  of  the  tube  and  the  treatment  of  the 
wound  do  not  absolutely  preclude  the  possibility  of  the 
development  of  septogenic  germs,  it  is  liable  to  become  a 
no  less  deadly  weapon  than  the  pistol  itself. 

The  reiterated  injunctions  to  observe  aseptic  care 
which  garnish  all  modern  discourse  upon  surgical  proce- 
dure doubtless  grow  wearisome ;  but  like  admonitions  to 
virtue  they  are  always  in  season,  and  are  nowhere  of  more 
vital  importance  than  when  they  concern  operations  within 
the  cranial  cavity.  The  arachnoid  is  more  sensitive  than 
the  peritoneum,  and  the  brain  less  tolerant  of  disturbance 
than  the  abdominal  visera ;  septic  infection  is  even  more 
prone  to  follow  errors  in  technique,  and  its  results  are 
more  disastrous  than  in  abdominal  operations.  In  explo- 
ration, therefore,  not  less  than  in  operation,  and  in  the 
general  treatment  of  intracranial  wounds,  the  most  rig- 
orous exactitude  is  demanded  in  every  detail  of  aseptic 
precaution.  The  responsibility  may  then  be  justifiably 
assumed  by  the  surgeon  of  using  such  methods  of  exami- 
nation as  are  necessary  to  an  intelligent  apprehension  of  the 
conditions  of  a  case  and  to  the  subsequent  adoption  of  the 
course  of  procedure  most  likely  to  insure  the  eventual 
safety  of  the  patient. 


surgical  relations.  387 

Prog^^osis. 

The  general  prognosis  of  intracranial  pistol-shot  wounds 
is  absolutely  bad ;  worse  probably  than  in  any  other  class 
of  bodily  injuries.  Its  numerical  expression,  while  not  to 
be  altogether  discarded,  is  of  comparatively  little  value. 
In  the  series  of  reported  cases  collected  for  the  present 
study  of  such  injuries,  the  fatalities  are  only  slightly  in 
excess  of  the  recoveries ;  these  cases,  however,  have  been 
exclusively  those  which  have  surviA'ed  primary  shock  and 
hemorrhage,  and  in  many  instances  they  have  been  avow- 
edly or  presumably  reported  because  they  were  recoveries, 
and  of  special  interest  on  that  account.  In  Bradford's 
tables,  again,  deaths  are  recorded  in  more  than  half  the 
total  number  of  ninety-one  cases ;  in  twenty-two  of  these,  a 
group  comprising  all  those  in  which  the  patient  lived  to 
reach  the  Boston  City  Hospital,  but  five  survived.  In 
Wharton's  tables  the  comparative  secondary  mortality  is 
practically  the  same.  Bryant's  tables  were  compiled  largely 
from  cases  not  of  pistol-shot  origin,  and  are  therefore  not 
pertinent  to  the  present  inquiry.  In  the  annexed  series  of 
personal  observations  death  occurred  at  once  or  within  the 
first  hour  in  fifteen  cases,  within  twelve  hours  in  seven 
cases,  and  in  from  fifteen  hours  to  forty  days  in  ten  cases. 
Apparent  recovery  followed  in  but  eight  cases.  This  last 
showing  of  comparative  results  is  still  fallacious,  as  only  a 
small  proportion  of  the  immediately  fatal  cases  is  brought 
under  professional  observation,  even  at  the  morgue.  As 
likely  to  afford  upon  a  scale  of  sufficient  magnitude  the 
most  exact  knowledge  possible  of  the  great  fatality  of 
pistol-shot  wounds  of  the  brain,  a  record  was  made  of  all 
such  cases  reported  in  the  New  York  Herald,  as  occurring 


388  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

in  New  York  and  its  immediate  neighborhood,  during  the 
year  ending  December  31,  1896.  This  summary  comprises 
accidents,  suicides,  and  homicides,  in  which  wounds  were 
inflicted  by  weapons  of  all  calibres  and  under  all  conceivable 
circumstances.  In  a  total  of  one  hundred  and  thirty-seven 
cases,  the  subject  was  found  dead  or  death  occurred  at  once 
in  ninety-nine ;  twenty-one  others  were  known  to  have 
proved  fatal  at  some  later  period,  from  a  few  hours  to  one 
or  two  days;  and  in  eleven  the  probable  result  is  not  indi- 
cated. In  six  cases  only  recovery  was  assured  or  can  be 
reasonably  inferred  from  the  circumstances  noted.  This 
comprehensive  notation  of  a  circumscribed  class  of  pistol- 
shot  wounds  permits  a  much  more  precise  estimate  of  gen- 
eral prognosis  than  could  be  made  from  clinical  observation. 
It  is  doubtful  if  statistical  researches  are  of  real  importance 
except  for  the  expression  of  such  elementary  facts.  They 
may  sufficiently  determine,  as  in  this  instance,  the  question 
of  general  prognosis,  expressed  in  numerical  terms,  since 
life  and  death  are  alone  involved  with  no  conditions  be- 
yond the  causation  and  location  of  the  wound. 

Death  is  the  result  in  so  large  a  gross  proportion  of 
cases  that  it  is  obvious  concomitant  circumstances  are  not 
largely  influential  in  prognosis.  In  .suicide  the  range  of 
fire  must  always  be  within  the  limit  in  which  necropsic 
observations  have  shown  that  it  does  not  materially  modify 
effects,  and  accidental  and  homicidal  wounds  are  usually 
inflicted  within  scarcely  greater  distances.  At  these 
ranges,  a  bullet,  whether  of  large  or  medium  calibre,  has 
sufficient  momentum  to  penetrate  the  cranium,  whatever 
its  density  or  thickness,  and  to  occasion  equally  extensive 
cerebral  injury.  Bullets  of  0.22  cal.,  however,  must  be 
excepted  from   these   general  statements   formulated  for 


SURGICAL    RELATIONS.  389 

missiles  of  larger  size.  It  has  been  noted  in  cadaveric  ex- 
perimentation that  with  this  calibre  penetration  is  less  cer- 
tain ;  it  may  fail  if  the  cranium  be  both  thick  and  dense, 
even  at  contact  or  at  short  ranges,  unless  the  ^veapon  be 
of  the  best  type  and  the  explosive  of  the  best  quality. 
The  difference  in  extent  of  cerebral  laceration  as  produced 
by  bullets  of  0.32,  0.38,  and  0.44  cal.,  though  sometimes 
manifest,  is  not  sufficient  to  be  of  practical  importance; 
but  with  a  bullet  of  0.22  cal.  it  is  distinctively  less, 
enough  so  to  diminish  the  primary  danger  from  shock  un- 
less some  large  meningeal  vessel  has  been  wounded.  It 
is  noticeable  on  a  recurrence  to  published  cases,  in  which 
immediate  danger  was  surmounted,  how  frequently  the 
calibre  when  mentioned  was  0.22  or  less;  and  wounds  of 
the  head  when  made  by  bullets  of  these  small  calibres 
have  been  generally  regarded  as  involving  a  minimum 
amount  of  danger.  The  proportion  of  absolute  recoveries 
is  doubtless  greater  than  with  the  larger  calibres,  not  only 
from  more  frequent  lack  of  penetration  and  from  lesser 
cerebral  laceration,  but  from  the  smaller  number  and 
minuter  size  of  the  osseous  fragments  which  are  driven 
into  the  brain  substance,  and  which  experience  has  shown 
to  be  the  most  active  agents  of  septic  infection.  The  re- 
coveries are  still  comparatively  few ;  the  most  vulnerable 
point  for  cranial  penetration  is  usually  though  ignorantly 
selected  in  suicides,  which  constitute  by  far  the  largest 
class  of  these  cases ;  and  if  an  immediately  fatal  hemor- 
rhage from  division  of  some  large  meningeal  vessel  is 
evaded,  the  smallness  of  the  bullet  permits  it  to  traverse 
long  distances  through  the  brain,  with  corresponding  lia- 
bility of  realizing  conditions  of  immediate  danger;  and 
though  it  reaches  some  distant  point,  in  which  it  is  lodged 


390  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

without  having  directly  brought  life  in  question,  there  still 
remains  the  peril  of  changes  in  organic  structure  from 
sepsis  or  irritation  which  may  make  death  its  inevitable 
sequel  though  long  deferred. 

The  one  important  element  of  special  prognosis  is  to 
be  found  in  treatment.  The  several  causes  of  death  are 
shock,  hemorrhage,  sepsis,  and  irritation  of  the  cerebral 
tissue  from  the  presence  of  a  foreign  body.  If  shock  is 
suflBcient  to  endanger  life,  there  is  not  often  time  for  in- 
terference, and  the  source  of  hemorrhage  is  likely  to  be 
beyond  the  reach  of  haemostatics ;  but  so  far  as  treatment 
is  possible,  there  can  be  little  question  as  to  its  methods 
and  none  which  can  modify  prognosis.  The  occurrence 
of  septic  infection,  which  is  an  imminent  danger  in  all 
cases,  and  to  which  the  majority  succumb,  may  be  amena- 
ble to  both  prophylactic  and  curative  means,  and  the  early 
extraction  of  the  bullet  and  osseous  fragments,  when  prac- 
ticable, obviates  the  later  danger  from  cerebral  irritation. 
The  resort  to  judicious  measures,  therefore,  for  the  pre- 
vention or  control  of  septic  infection,  and  for  the  removal 
of  causes  of  cerebral  irritation  on  the  one  hand,  or  the 
abstention  from  their  use  on  the  other,  must  necessarily 
influence  the  result  in  individual  cases  and  become  a  factor 
in  its  prediction. 

The  better  chances  of  recovery  when  the  necessary 
means  are  employed  for  thorough  exploration  of  the  wound 
for  the  removal  of  septic  foreign  bodies,  and  for  the  main- 
tenance of  aseptic  conditions,  is  evident  from  analysis  of 
the  practically  complete  series  of  published  cases.  A 
study  of  this  character  to  determine  general  principles  is 
apart  from  mere  statistical  tabulation,  in  which  incongru- 
ous cases  are  collated,  and  in  which  from  the  omission  of 


SURGICAL    RELATIONS.  39I 

necessary  elements  of  comparison  untrustworthy  conclu- 
sions are  deduced.  The  established  facts  that  in  the  case 
of  patients  surviving  the  immediate  effects  of  injury  a 
majority  die  either  at  once  from  sepsis,  the  result  of  the 
retention  of  foreign  bodies  within  the  cranial  cavity  and  a 
concomitant  lack  of  disinfection,  or  at  a  later  period  from 
the  irritation  which  they  occasion,  and  that  present  surgi- 
cal resources  are  adequate  to  avert  danger  of  primary  or 
added  septic  infection  from  operative  interference  itself, 
make  the  conclusion  irresistible  that  exploration  and  if 
possible  the  removal  of  the  bullet  and  other  alien  sub- 
stances increase  the  prospects  of  recovery,  whatever  may  be 
the  attendant  conditions.  The  cases  which  have  collec- 
tively afforded  these  basic  facts  have  been  sufficently  ana- 
lyzed and  summarized  in  the  previous  consideration  of 
treatment. 

The  choice  of  means,  of  instrumentalities  to  be  em- 
ployed in  the  application  of  the  general  principle,  has  not 
been  similarly  determined,  though  various  authors  have 
tabulated  results  with  this  purpose  in  view.  They  have 
failed  in  showing  either  that  essential  conditions  were 
comparable  or  that  proper  discretion  was  exercised  by  the 
surgeon.  Elaborate  computations  of  the  number  of  cases 
probed,  trephined,  or  subjected  to  no  interference  what- 
ever, and  made  with  sole  reference  to  the  death  or  recov- 
ery of  the  patient,  or  enumeration  of  the  results  of  wounds 
of  the  several  cerebral  lobes  inflicted  under  diverse  condi- 
tions, simply  add  to  that  constantly  growing  fund  of  use- 
less knowledge  to  which  the  most  of  us  are  misguided  if 
not  guilty  contributors.  The  bald  fact  that  death  followed 
the  use  of  the  probe  or  of  the  trephine  in  a  certain  number 
of  cases  and  recovery  in  a  certain  number  of  others,  while 


392  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

neither  the  necessity  for  its  use  nor  the  manner  of  it, 
neither  the  previous  hopeless  or  hopeful  condition  of  the 
patient  nor  his  subsequent  treatment,  is  in  evidence  or  is 
given  consideration,  is  not  only  unimportant,  but  when 
stated  with  the  formality  of  a  statistical  result  is  likely  to 
be  positively  mischievous  as  leading  to  unjustifiable  infer- 
ence. In  like  manner,  the  formulated  fact  that  in  a  limited 
number  of  cases  with  imperfect  histories  a  greater  num- 
ber of  deaths  occurred  with  or  without  resort  to  operative 
measures  can  have  no  legitimate  value  as  a  basis  for  con- 
clusion or  practice.  The  opinion  which  has  obtained,  and 
is  reflected  in  the  histories  of  cases,  that  a  bullet  once 
within  the  cranial  walls  is  tapu,  and  which  has  more  than 
once  permitted  a  patient  to  die  from  septic  infection  with- 
out examination  of  his  wound,  and  with  a  bullet  or  osseous 
fragments  lying  almost  upon  the  cerebral  surface,  has  had 
its  origin  in  a  fatuous  belief  that  numerical  statements  are 
infallible  and  that  treatment  is  to  be  conducted  in  accord- 
ance with  inflexible  rules.  The  general  method  of  treat- 
ment is  to  be  deduced  from  the  general  laws  of  surgical 
procedure  and  confirmed  by  the  results  of  observation  ;  but 
its  details  in  their  application  to  individual  cases  involve 
so  complex  and  unstable  conditions  that  they  must  be  de- 
termined in  each  instance  by  the  judgment  of  the  surgeon. 
The  thorough  exploration  of  the  wound,  and  if  possible 
the  extraction  of  foreign  bodies,  are  prescriptive;  the 
practicability  of  operation,  and  the  means  for  its  accom- 
plishment, lie  within  his  discretion. 


THE   CONDENSED    HISTORIES   OF 

THREE   HUNDRED 
INTRACRANIAL  TRAUMATISMS 

SELECTED    FROM   A   SERIES 
OF    FIVE   HUNDRED   ORIGINAL   CASES 


I. 

CASES   VERIFIED    BY    NECROPSY. 
Fractures  of  the  Cranial  Base. 

Case  I.  Symptoms. — Wound  in  left  posterior  parietal 
region;  hemorrhage  from  left  ear;  wild  delirium;  high 
temperature ;  coma.     Death  in  forty-eight  hours. 

Lesions. — Fracture  of  left  temporal  bone,  with  sep- 
aration of  its  constituent  parts — squamous,  petrous,  and 
mastoid.  Laceration  of  both  parietal  and  right  temporal 
lobes. 

Case  II.  Symptoms. — Delirium,  which  was  considered 
alcoholic ;  walking  case ;  treatment  refused ;  suicide  by 
drowning  on  the  following  day. 

Lesions. — Fracture  extending  from  left  parietal  emi- 
nence to  foramen  magnum.  General  cerebral  and  menin- 
geal contusion,  and  cortical  laceration  of  right  temporal 
lobe. 

Case  III.  Symptoms. — Wound  in  right  superior  pos- 
terior parietal  region ;  hemorrhage  from  right  ear  and 
later  from  right  nostril.  Coma;  stertor;  general  muscular 
rigidity;  dilatation  of  left  pupil;  left  hemiplegia  after 
twelve  hours,  and  recurrence  of  hemorrhage  from  the  ear, 
with  disappearance  of  stertor  and  muscular  rigidity ;  urine 
not  controlled;  consciousness  not  regained.  Death  in  six 
days. 

Lesions. — Fracture  extending  from  point  of  injury 
through  right  petrous  portion  and  middle  fossa.  Lacera- 
tion of  inferior  and  external  surfaces  of  left  frontal  and 
right  temporal  lobes;  corresponding  cortical  hemorrhages, 
thinning  toward  base  and  vertex;  excessive  general  hyper- 
semia. 


396  INJURIES    OF    THE    BRAIN   AND    MEMBRANES. 

Case  IV.  Symptoms. — Compound  depressed  fracture, 
external  to  right  parietal  eminence ;  found  on  trephination 
to  be  confined  to  external  table,  with  fissures  extend- 
ing into  middle  fossa.  Semi-consciousness,  mild  delirium, 
imperfect  articulation,  with  slow  and  irregular  respiration, 
which  continued  for  three  days ;  paralysis  of  right  upper 
extremity  and  of  right  upper  and  lower  face,  differing  in 
degree  at  different  times;  mental  condition  varying  from 
normal  to  one  of  noisy  delirium ;  patient  usually  restless, 
and  during  last  two  days  unconscious.  Temperature  on 
admission,  101°;  during  first  week,  100°;  in  second  week, 
99°  -|-  ;  and  rose  steadily  from  103°  to  109°  through  last 
two  days.     Death  in  forty-five  days. 

Lesions. — Subarachnoid  serous  effusion ;  subcortical  cav- 
ity beneath  the  point  of  osseous  depression,  of  large  size, 
containing  a  reddish  semifluid  material  and  brown  detri- 
tus ;  cortex  not  wounded ;  excessive  general  hyperaemia. 

Case  V.  Symptoms. — Stupor;  gradual  unconscious- 
ness; delirium  requiring  mechanical  restraint.  Temper- 
ature on  admission,  102°;  ten  hours  later,  105°;  declined 
to  101.8°,  and  then  rose  steadily  to  106.6°.  Death  in 
twenty-nine  hours. 

Lesions. — Wound  over  occipital  tuber,  and  extravasa- 
tion of  blood  over  whole  calvarium ;  no  fracture  of  vertex, 
but  a  fine  fissure  along  posterior  border  of  right  petrous 
portion.  Pial  hemorrhage  over  superior  surface  of  both 
hemispheres;  laceration  of  left  frontal,  and  both  temporal 
lobes,  and  of  inner  border  of  right  frontal  lobe. 

Case  VI.  Symptoms. — Stupor;  incoherence;  dilatation 
of  left  pupil ;  slight  deviation  of  eyes  to  the  right ;  later, 
delusions,  delirium,  muscular  tremor,  irregular  pupils, 
frequent  and  intermittent  pulse.  Temperature  on  admis- 
sion, 103°;  five  hours  later,  102°;  and  rose  to  106.2°. 
Death  in  twenty-four  hours. 

Lesions. — Wound  in  right  parietal  region;  linear  frac- 
ture extending  through  whole  length  of  right  parietal  and 
occipital  bones,  and  through  petrous  portion  into  middle 


CASES    VERIFIED    BY    NECROPSY.  397 

fossa;  considerable  laceration  of  inferior  surface  of  left 
frontal  and  of  left  temporal  lobes. 

Case  VII.  Symptoms. — Patient  fell  upon  the  sidewalk, 
and  was  admitted  to  the  hospital  twenty-four  hours  later. 
CEdema  of  the  scalp  under  and  about  an  old  cicatrix  be- 
hind the  right  ear,  and  beneath  this  an  extensive  commi- 
nuted fracture;  two  fragments  of  bone  were  removed,  and 
one  was  elevated,  and  a  large  epidural  clot  extracted  as 
far  as  possible.  Stupor;  hemorrhage  from  right  ear;  ir- 
regular pupils;  general  muscular  rigidity;  ataxic  gait: 
diminished  sensibility,  and  loss  .of  urinary  control.  On 
the  fourth  day  temperature  normal,  mind  clear,  and  mus- 
cular rigidity  lessened ;  copious  serous  discharge  from 
right  ear  and  right  facial  paralysis;  on  the  fifth  day  in- 
creased muscular  rigidity  and  recurrence  of  stupor;  on  the 
sixth  day,  unconsciousness  and  frequent  general  convul- 
sions. Temperature  on  admission,  twenty-four  hours  after 
injury  99°  -{- ;  on  the  fourth  day,  normal ;  on  the  fifth 
day,  100°  -|-  ;  on  the  seventh  day,  105°.  Death  on  the 
seventh  day. 

Lesions. — The  whole  central  portion  of  the  occipital 
bone  from  the  foramen  magnum  upward,  and  posterior  por- 
tion of  both  parietal  and  right  temporal  bones,  forming  an  ir- 
regular circle  from  two  inches  and  a  half  to  three  inches  in 
diameter,  were  broken  into  large  fragments,  two  of  which 
had  been  removed  during  life.  The  mastoid  and  outer 
part  of  the  petrous  portion  of  the  right  temporal  bone 
could  be  removed  by  the  fingers  with  the  use  of  very  little 
force.  This  line  of  fracture  ran  through  the  tympanic 
cavity,  so  that  after  removal  of  the  outer  fragment  the 
carotid  canal  and  aqueductus  Fallopii,  filled  with  coagula, 
could  be  seen  in  the  section.  A  large  epidural  clot  was  sit- 
uated beneath  the  occipital  fracture,  extending  half  an 
inch  beyond  its  margin.  A  large  subdural  clot  filled  the 
right  inferior  occipital  fossa,  extending  to  the  foramen 
magnum.  The  cavity  of  the  posterior  part  of  the  great 
longitudinal  sinus  was   occupied  by   a  thrombus,  and  its 


398  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

walls  were  infiltrated  with  blood.  There  was  a  large  par- 
tially decomposed  thrombus  in  the  torcular  Herophili,  ex- 
tending through  the  right  lateral  into  the  petrosal  sinus 
and  internal  jugular  vein.  The  whole  internal  surface  of 
the  dura  beneath  the  seat  of  the  external  hemorrhage  was 
lined  by  a  firmly  coagulated  clot  with  an  inflammatory  ex- 
udation around  it.  A  portion  of  the  surface  of  the  right 
occipital  lobe  posteriorly  was  softened,  showed  minute 
hemorrhages,  and  was  torn  away  in  the  removal  of  the 
dura.  The  meshes  of  the  pia  mater  over  a  large  part  of 
the  parietal  and  occipital  lobes  posteriorly  were  dis- 
tended with  slightly  turbid  serum.  There  was  a  small 
laceration  on  the  under  surface  of  each  frontal  lobe 
and  a  larger  one,  three-quarters  of  an  inch  in  diameter, 
in  the  right  cerebellum  at  a  point  corresponding  to 
the  site  of  the  thickest  part  of  the  subdural  hem- 
orrhage. 

Case  VIII.  Symptoms. — CEdema  of  scalp  in  right  pa- 
rietal region,  and  fracture  discovered  by  incision.  Coma, 
stertor,  general  muscular  rigidity  most  marked  on  the 
right  side,  and  strong  contraction  of  both  pupils  most 
marked  in  the  left;  no  change  in  general  condition  till 
death  fifty-four  hours  later.  Temperature  on  admission, 
100.4°,  rising  progressively  to  103.8°,  with  immediate 
post-mortem  recession. 

Lesiojis. — Fracture  extending  from  posterior  and  infe- 
rior part  of  right  parietal  bone  to  right  jugular  foramen, 
and  then  turning  backward  to  foramen  magnum.  Lacera- 
tion of  anterior  border  of  left  temporo-sphenoidal  lobe  and 
of  the  anterior  and  internal  borders  of  both  frontal  lobes; 
cortical  hemorrhage  covering  the  whole  base  of  the  brain ; 
subcortical  laceration  with  clot  occupying  the  whole  inte- 
rior of  the  left  frontal  and  temporo-sphenoidal  lobes,  and 
filling  with  blood  both  lateral  ventricles  and  both  occipital 
lobes ;  slight  epidural  hemorrhage  at  point  where  fracture 
began  in  right  inferior  and  posterior  parietal  region ;  slight 
subarachnoid  serous  effusion ;    thrombus  extending  from 


CASES  VERIFIED   BY   NECROPSY.  399 

torcular  Herophili  through  right  occipital  and  inferior 
petrosal  sinuses  into  the  jugular  vein. 

Case  IX.  Symptoms. — Partial  unconsciousness  for 
twenty-four  hours;  became  complete;  hemorrhage  from 
both  nostrils  and  from  right  ear;  delirium  on  the  fifth 
day  with  post-cervical  muscular  rigidity,  restlessness,  and 
retraction  of  the  abdomen ;  Cheyne-Stokes  respiration  and 
death.  Temperature  for  three  days,  99.2°;  on  the  fourth 
day,  103.2°;  on  the  fifth  day,  104.8°. 

Lesions. — Contusion  over  right  mastoid  revealed  on 
raising  the  scalp.  Fracture  at  base  in  three  fissures,  ex- 
tending from  this  point;  two  (fine)  across  petrous  portion, 
and  a  third  connecting  these  posteriorly  across  occipital 
bone.  Deep  linear  laceration,  extending  across  inferior 
surface  of  right  cerebellum,  near  outer  border.  Cortical 
hemorrhage  over  whole  left  cerebrum,  superiorly  and  lat- 
erally; most  copious  in  middle  lateral  region.  Laceration 
of  antero-inferior  border  of  left  frontal  lobe.  White  sub- 
stance of  left  cerebrum  much  congested,  and  with  punc- 
tate extravasations  throughout  its  extent. 

Case  X.  Symptoms. — Semi-consciousness  and  left 
hemiplegia,  followed  by  irritability;  hemorrhage  from 
left  nostril ;  depressed  fracture  involving  left  frontal  emi- 
nence; bone  elevated.     Death  in  twenty-four  hours. 

Lesions.  —  Coronal  suture  separated  on  right  side; 
multiple  fissures,  one  extending  through  bod}'  of  sphe- 
noid bone  into  left  middle  fossa,  and  others  through  right 
middle  and  anterior  fossae,  external  to  orbital  plate. 
Epidural  hemorrhage  in  left  temporal  region;  laceration 
of  right  frontal  and  right  temporal  lobes,  and  of  left  tem- 
poral lobe. 

Case  XI.  Symptoms. — Coma,  stertor,  dilatation  of  left 
and  contraction  of  right  pupil,  paraplegia,  hemorrhage 
from  left  ear  and  nose  and  under  left  conjunctiva,  and 
contusion  over  left  eye.  Death  in  five  minutes  after  ad- 
mission. 

Lesions. — Linear  fracture  extending  downward  and  for- 


400  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

ward  from  behind  left  parietal  eminence,  across  petrous 
portion,  through  middle  fossa,  transversely  across  anterior 
fossa,  and  terminating  in  right  lesser  wing  of  sphenoid 
bone.  Epidural  hemorrhage,  blood  still  fluid ;  slight 
lacerations  of  inferior  surface  of  left  frontal  and  temporal 
lobes  and  trivial  cortical  hemorrhage;  excessive  general 
hyperaemia. 

Case  XII.  Symptonis. — Contusion  in  right  parietal  re- 
gion, hemorrhage  from  left  ear  and  nose,  loss  of  faecal  and 
urinary  control,  right  hemiplegia;  temperature  on  admis- 
sion, 99.4°.     Death  in  two  days. 

Lesions. — Fracture  extending  from  right  parietal  emi- 
nence to  foramen  magnum,  of  right  petrous  portion  through 
its  whole  length,  and  of  left  petrous  portion  for  two  inches. 
Laceration  of  left  parietal  lobe,  and  cortical  hemorrhage. 

Case  XIII.  Symptoms. — Coma,  stertor;  normal  pulse, 
respiration,  and  pupils.     Death  in  five  days. 

Lesions. — Fracture  extending  from  beneath  a  contusion 
near  right  parietal  eminence  downward  and  forward, 
anterior  to  petrous  portion,  through  middle  fossa  and  sella 
turcica.  Pial  hemorrhage  over  both  hemispheres;  lacera- 
tion of  inferior  surface  of  left  temporal  lobe. 

Case  XIV.  Symptoms. — Patient  knocked  down  by  a 
blow  in  the  face ;  momentarily  unconscious,  then  walked 
to  the  hospital,  and  afterward  walked  home.  Severe  pain 
in  head  for  three  hours,  gradual  supervention  of  coma, 
which  became  complete  in  four  hours.  Death  in  eight 
hours. 

Lesions. — Wound  of  lip  and  contusion  of  forehead. 
Linear  fracture  of  external  table  extending  from  right 
inferior  occipital  fossa  across  petrous  portion.  Slight  epi- 
dural hemorrhage  beneath  the  fracture ;  large  pial  hemor- 
rhage over  external  aspect  of  left  frontal  and  parietal  lobes, 
with  some  extravasations  into  the  pia  mater;  slight  limited 
contusions  of  brain  substance. 

Case  XV.  Symptoms. — Coma;  dilatation  of  right  and 
contraction  of  left  pupil ;  right  hemiplegia ;  pulse  became 


CASES   VERIFIED    BY   NECROPSY.  4OI 

slower,  ana  respiration  more  labored.  Death  in  nine  and 
one-half  hours. 

Lesions. — Contusion  in  left  parietal  region,  and  fracture 
extending  from  that  point  by  two  fissures  through  pa- 
rietal bone  into  anterior  and  middle  fossae.  Large  epi- 
dural hemorrhage  from  rupture  of  left  middle  meningeal 
artery ;  slight  laceration  of  left  parietal  lobe  at  point  where 
fracture  began  and  another  upon  lateral  border  of  left 
temporal  lobe. 

Case  XVI.  Symptoms. — Loss  of  consciousness  followed 
by  stupor,  slight  but  increasing  dilatation  of  left  pupil, 
slight  hemorrhage  from  left  ear,  slight  rigidity  of  left 
side,  and  labored  respiration ;  temperature  99° ;  left 
hemiplegia  first  affecting  lower  extremity ;  temperature 
101.2°.     Death  in  twenty-one  hours. 

Lesions. — Contusion  of  scalp  in  left  occipito-parietal  re- 
gion; stellate  fracture  in  centre  of  left  parietal  bone:  fis- 
sures which  extended  toward  median  line,  into  inferior 
occipital  fossa,  and  along  upper  border  of  petrous  por- 
tion into  middle  fossa.  Recent  laceration  of  inferior  and 
lateral  surfaces  of  right  temporal  lobe,  and  of  inferior 
surface  of  both  frontal  lobes  along  median  fissure ;  old 
laceration  of  inferior  surface  of  left  temporal  lobe ;  deep 
and  irregular  in  outline,  lined  with  a  grayish-yellow  Yiscid 
substance,  surrounded  b}'  an  area  of  3'ellow  softening,  and 
about  one  inch  in  its  several  diameters ;  smaller  old  lacera- 
tions, presenting  similar  characters,  of  inferior  surface 
of  left  frontal  lobe.  The  recent  right  temporal  lacera- 
tion Avas  of  large  extent.  Extensive  cortical  hemorrhage 
over  right  cerebrum,  and  well-marked  general  hyperemia 
of  brain. 

Case  XVIL  Symptoms. — Loss  of  consciousness,  dilata- 
tion of  right  and  contraction  of  left  pupil,  right  hemiple- 
gia, full  and  slow  respiration ;  pulse,  66.  Death  in  eleven 
hours. 

Lesions. — Contusion  of  left  parietal  region,  from  the 
site  of  which  one  fissure  extended  into  the  anterior  and 
26 


402  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

another  into  the  posterior  fossae.  Large  epidural  hemor- 
rhage from  rupture  of  left  middle  meningeal  artery;  gen- 
eral hyperaemia  with  minute  coagula  and  punctate  extra- 
vasations. 

Case  XVIII.  Symptoms. — Loss  of  consciousness  for 
thirty  minutes,  subsequent  irritability  when  disturbed; 
temperature,  98°;  pulse,  78  and  intermittent;  depressed 
fracture  below  right  temporal  ridge,  and  hemorrhage  from 
right  ear.  Second  day:  depressed  bone  elevated,  and 
three  fissures  disclosed — one  running  backward,  one  for- 
ward, and  one  downward^  dura  incised;  temperature, 
101.8°.  Third  day:  somnolence  and  irritability,  loss 
of  urinary  control;  temperature,  102°.  Fourth  day: 
delirium  and  progressive  rise  of  temperature  to  105.4°. 
Fifth  day:  moderate  dilatation  of  pupils,  restlessness, 
hyperaesthesia,  increase  of  surface  heat,  followed  by  deep 
coma.  The  temperature  from  this  time  varied  each  day 
from  104°-]-  in  the  morning  to  io5°-j-  in  the  evening 
till  death  on  the  eighth  day,  and  was  then  106°. 

Lesions. — Skull  thin.  No  pus  in  the  wound  or  in  the 
small  brain  cavity  which  had  been  disclosed  by  the  ante- 
mortem  operation  when  the  depressed  bone  was  elevated. 
Subdural  hemorrhage  in  the  opposite  (left)  occipito-parie- 
tal  region.  An  effusion  of  thick  green  pus  beneath  the 
arachnoid  membrane  covered  the  lateral  and  superior  sur- 
faces of  the  right  occipital  and  parietal  lobes,  but  did  not 
extend  forward  to  within  an  inch  of  the  cranial  opening 
left  by  operation.  A  subdural  effusion  of  similar  thick 
green  pus  was  coextensive  with  the  whole  right  inferior 
occipital  fossa.  There  was  a  deep  laceration,  one  inch 
in  diameter,  upon  the  lateral  border  of  the  left  temporo- 
sphenoidal  lobe,  which  involved  the  subcortical  tissue.  At 
a  point  directly  beneath  the  opening  left  by  the  removal 
of  the  depressed  bone  there  was  a  cavity  in  the  brain 
substance  as  large  as  a  hickory  nut,  which  opened  by  its 
whole  extent  upon  the  cerebral  surface.  (As  this  surface 
v/as  intact  at  time  of  operation,  the  cavity  must  be  ascribed 


CASES    VERIFIED    BY   NECROPSY.  403 

to  a  direct  contusion,  subcortical,  not  involving  superficial 
laceration,  and  to  a  subsequent  giving  way  of  the  cerebral 
cortex  under  the  influence  of  arterial  pulsation,  and  in  the 
absence  of  normal  repressive  force  exerted  by  the  skull 
and  dura  mater.  The  whole  brain  substance  and  menin- 
geal vessels  were  intensely  hyperaemic,  and  there  w^ere 
numerous  minute  extravasations  from  general  contusion. 
There  was  no  meningeal  or  ventricular  serous  effusion. 
A  fissure  extended  from  the  central  point  of  fracture 
through  the  petrous  portion  of  the  temporal  and  inferior 
occipital  fossa  to  the  foramen  magnum. 

Case  XIX.  Symptoms. — Permanent  unconsciousness; 
irritability  when  disturbed ;  dilatation  of  both  pupils,  es- 
pecially marked  in  right;  profuse  hemorrhage  from  left 
ear,  which  continued  for  tw-enty-four  hours,  and  was  then 
followed  by  serous  discharge;  general  convulsive  move- 
ments, most  pronounced  in  right  leg;  temperature,  100°; 
pulse,  80;  single  general  convulsion,  most  violent  on  left 
side  on  second  day,  and  repeated  on  third  day;  tempera- 
ture rose  steadily  to  107.2°.  Death  in  three  days  and  six 
hours. 

Lesions. — Large  hsematoma  in  substance  of  left  tem- 
poral muscle.  Fracture  extended  from  left  squamous  por- 
tion into  middle  fossa,  and  by  an  open  fissure  along  an- 
terior border  of  petrous  portion  to  the  sella  turcica.  Large 
epidural  clot  in  left  middle  fossa;  large  and  deep  lacera- 
tion of  lateral  surface  of  left  temporo-sphenoidal,  and  of 
lateral  and  inferior  surfaces  of  right  temporo-sphenoidal 
lobes ;  small  and  deep  laceration  at  right  parieto-occipital 
junction;  large  cortical  clot  in  left  middle  fossa;  thin  cor- 
tical coagulum  over  right  cerebrum. 

Case  XX.  Symptoms. — Contusion  of  left  parietal  re- 
gion and  of  both  eyes.  Loss  of  consciousness,  and  mutter- 
ing incoherence  when  disturbed;  subconjunctival  hemor- 
rhage at  outer  part  of  left  eye ;  slight  temporary  rigidity 
of  right  arm;  restlessness  and  irritability;  little  change 
till  death,  in  seven  days  ten  hours.     Temperature  on  ad- 


404  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

mission,  101°;  in  two  days  rose  to  104.8°;  declined  from 
fourth  to  sixth  days  to  ioi°-f-  to  i02°4->  and  then  rose 
progressively  to  107°  +. 

Lesions. — Skull  thin ;  fracture  of  left  anterior  and  mid- 
dle fossae,  apparently  beginning  with  a  comminution  of 
orbital  plate  of  left  frontal  bone  about  its  centre.  At  this 
point  two  or  three  small  fragments  were  displaced  upward, 
with  fine  fissures  extending  in  different  directions.  One 
fi-ssure  ran  outward  and  upward  into  left  squamous  portion 
of  the  temporal  bone ;  another  ran  backward  from  the  crista 
galli  through  the  bodies  of  the  ethmoid  and  sphenoid 
bones,  through  the  optic  foramen,  and  along  the  anterior 
border  of  the  petrous  portion ;  and  the  third  ran  through 
the  right  optic  foramen  into  the  squamous  portion  of  the 
right  temporal  bone.  The  optic  nerves  were  uninjured. 
There  was  a  little  blood  extra vasated  over  right  occipital, 
and  lower  part  of  right  parietal  lobes.  The  left  frontal 
lobe  was  completely  excavated  by  a  laceration,  which  was 
bounded  everywhere  by  a  thin  layer  of  unaltered  cortex, 
except  inferiorly,  near  the  anterior  border,  where  it  was 
covered  in  only  by  the  meninges.  It  was  separated  from 
the  ventricle  by  a  thin  septum  of  brain  substance.  This 
cavity  contained  commingled  blood,  clot,  and  brain  detri- 
tus. There  was  also  a  laceration  of  the  anterior  two-thirds 
of  the  external  lateral  border  of  the  right  cerebellum,  and 
an  extravasation  of  the  size  of  a  robin  shot  in  the  centre  of 
the  right  corpus  striatum.  There  was  no  clot  anywhere  at 
the  base  of  the  brain  and  no  other  lesions. 

Case  XXI.  Symptoms. — Patient  while  in  an  alcoholic 
condition  fell  seventeen  feet  into  the  hold  of  a  vessel. 
Thirty  minutes  later  when  examined  he  was  unconscious, 
bleeding  from  the  mouth  and  nose,  and  said  to  have  been 
in  the  interval  violent  and  abusive.  He  was  three  times 
in  the  course  of  the  ensuing  twelve  hours  refused  surgical 
aid  by  ambulance  surgeons,  who  decided  that  he  was  suf- 
fering from  simple  alcoholic  intoxication.  He  was  then 
taken  to  a  police  court  conscious,  apparently  rational,  but 


CASES   VERIFIED    BY   NECROPSY.  405 

unable  to  stand  or  walk,  and  sentenced  to  imprisonment 
for  drunkenness.  As  an  afterthought  he  was  sent  to  the 
alcoholic  ward  of  Bellevue  Hospital,  and  later  transferred 
to  a  surgical  division.  There  was  then  severe  contusion 
of  the  face  and  eyes,  and  a  depressed  fracture  was  readily 
detected  in  the  right  frontal  region;  there  was  subcon- 
junctival hemorrhage  in  both  eyes,  muscular  rigidity  of 
both  arms,  slow  pulse,  and  labored  respiration,  soon  fol- 
lowed by  restlessness,  muttering  delirium,  loss  of  urinary 
control,  and  Cheyne-Stokes  respiration.  Temperature, 
104.8°  to  106°.     Death  in  twenty-four  hours  after  injury. 

Lesions. — Linear  fracture  of  the  temporal  bone  extend- 
ing three  inches  upward  and  backward  from  its  anterior 
border;  stellate  fracture  with  depression  above  the  right 
supra-orbital  ridge,  which  on  the  inner  surface  extended 
across  both  orbital  plates,  through  the  ethmoid  and  the 
body  of  the  sphenoid  bone,  and  on  the  left  side  through 
the  middle  fossa  nearly  to  the  petrous  portion  ;  nasal  bones 
comminuted.  There  was  no  considerable  intracranial 
hemorrhage ;  laceration  of  superior  surface  of  both  frontal 
and  both  parietal  lobes. 

Case  XXII.  Symptoms. — Coma,  stertor,  full  pulse, 
hemorrhage  from  the  right  ear,  and  pulmonary  oedema  for 
which  he  had  been  bled  from  the  arm  by  a  ship's  surgeon 
before  admission.     Death  in  two  hours. 

Lesions. — Hasmatoma  over  the  whole  right  side  of  the 
head.  Multiple  fissures  of  the  base  (six  in  number),  involv- 
ing both  sides  and  all  the  fossae.  The  primary  fissure,  of 
five  which  were  connected,  began  as  a  wide  fissure  behind 
and  a  little  to  the  left  of  the  foramen  magnum,  and  narrowed 
to  a  hair's  breadth  as  it  ran  forward  to  the  right  supercili- 
ary ridge.  A  sixth  and  entirely  independent  fissure  ran 
backward  from  the  crista  galli  on  the  left  side  through  the 
optic  foramen  to  the  sella  turcica.  There  were  slight  lacer- 
ations of  the  under  surface  of  both  frontal  and  right  temporo- 
sphenoidal  lobes,  which  occasioned  slight  cortical  hemor- 
rhage; an  epidural  hemorrhage  upon  the  upper  and  lateral 


406  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

surfaces  of  the  hemispheres,  especially  the  left,  and  at  the 
base,  in  the  inferior  occipital  fossae. 

Case  XXIII.  Symptoms. — Patient  found  at  foot  of  cel- 
lar stairs,  unconscious  and  restless,  with  a  large  lacerated 
scalp  wound,  which  had  bled  freely,  and  several  wounds 
of  the  face.  Admitted  to  the  alcoholic  ward  on  the  diag- 
nosis of  ambulance  surgeon  of  another  hospital,  still  un- 
conscious. The  scalp  wound  was  in  the  parieto-occipital  re- 
gion, to  the  right  of  the  median  line,  and  the  most  extensive 
face  wound  was  over  the  right  malar  bone.  As  he  did  not 
"  clear  up,"  he  was  transferred  to  a  surgical  ward  four  days 
afterward.  He  was  then  nearly  comatose,  quiet  unless 
disturbed ;  his  pupils  were  normal,  and  respiration  was  slow 
and  regular.  Temperature,  102.2°;  pulse,  96.  Tempera- 
ture next  day  was  104.6°,  103.6°,  and  106°;  and  on  the 
morning  after  it  was  105°  and  107°,  when  he  died  without 
further  symptoms,  five  days  and  a  half  after  reception  of 
injury. 

Lesions. — Fracture  at  base,  through  petrous  portion  of 
left  temporal  bone,  extending  to  foramen  magnum.  Lacer- 
ation of  left  temporal  and  frontal  lobes,  with  cortical 
hemorrhage. 

Case  XXIV.  Symptoms. — A  woman,  aged  thirty-eight ; 
habitual  criminal ;  jumped  from  the  third  tier  of  the  Tombs 
Prison  to  the  flagging  below,  thirty  feet  or  more;  punc- 
tured wound  in  left  occipito-parietal  region;  unconscious; 
hemorrhage  from  left  ear;  pupils  moderately  dilated,  more 
especially  the  left;  and  vomiting  persistent.  Temper- 
ature, 98.9°.  The  next  morning  the  patient  was  con- 
scious, rational,  and  the  hemorrhage  had  nearly  ceased. 
In  the  evening  she  was  slightly  delirious,  and  the  follow- 
ing day  required  mechanical  restraint  till  quieted  by  seda- 
tives. Both  pupils  became  widely  dilated,  the  left  still 
continuing  more  dilated  than  the  right,  and  they  were 
only  slightly  responsive  to  strong  artificial  light.  This 
ocular  condition  continued  till  her  death.  The  abdomen 
was  painful  and  swollen.     Her  mind  remained  clear  but 


CASES   VERIFIED    BY   NECROPSY.  407 

apathetic  till  the  sixth  day,  when  she  fell  into  a  stupor. 
On  the  same  day  all  the  extremities  became  paretic  and 
partially  ansesthetic.  Up  to  this  time  the  muscular  power 
had  been  normal.  The  paresis  and  aucesthesia  were  most 
marked  on  the  right  side.  The  pulse  was  rapid,  quick,  and 
feeble.  A  day  later  the  left  foot  and  right  hand  were  less 
paretic,  and  her  mind  was  clear  but  the  senses  were  blunted. 
She  answered  questions  slowl}^  and  after  an  interval,  and 
complained  of  pain  in  the  head.  On  the  eighth  day  she 
was  restless  and  irritable,  and  had  some  right  facial  paral- 
3'sis,  while  power  in  the  left  foot  and  right  hand  was  still 
further  improved.  On  the  ninth  day  she  was  delirious 
and  unconscious.  On  the  eleventh  day  she  no  longer 
moved  or  spoke,  and  paid  no  attention  to  an  explorative 
incision.  On  the  fifteenth  day  she  died  from  asthenia. 
The  temperature  remained  below  100°  till  the  close  of 
the  fourth  day,  when  it  rose  to  103°.  After  that  it  va- 
ried from  100°  to  i02°-j-;  usually  was  101°-)-  till  the 
twelfth  day,  when  it  rose  to  104°  F.,  and  was  afterward 
from  103°  to  104.5°  till  she  died. 

Lesions. — Head  large  and  unsymmetrical,  and  skull 
thick.  No  lesion  of  the  scalp  or  of  the  bone  was  discovered 
before  removing  the  calvarium.  The  occiput  was  dispro- 
portionately large,  and  the  right  occipital  fossae  were  much 
larger  than  the  left.  The  left  middle  and  anterior  fossse 
were  rather  larger  than  the  right.  A  fissure  began  at  a 
point  in  the  squamous  portion  of  the  left  temporal  bone, 
beneath  the  external  wound,  and,  passing  through  the  an- 
terior surface  of  the  petrous  portion,  terminated  in  the 
optic  foramen.  This  fissure  was  not  open,  but  the  frag- 
ments were  quite  movable.  There  was  no  epidural  hemor- 
rhage, but  pressure  was  made  upon  the  facial  nerve  by 
interosseous  hemorrhage  as  a  result  of  the  fracture.  There 
was  no  arachnitis  and  scarcely  the  usual  amount  of  serum 
in  the  meshes  of  the  pia.  There  were  slight  lacerations 
upon  the  under  surface  of  the  right  temporo-sphenoidal 
lobe,  and  one  somewhat  larger  upon  its  external  border. 


408  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

from  which  a  moderate  amount  of  blood  had  spread  up- 
ward over  the  occipital  lobe,  barely  reaching  the  parietal. 
Upon  section,  the  cerebral  vessels  were  found  to  be  dis- 
tended with  blood,  which  flowed  from  the  puncta  vascu- 
losa.  The  veins  could  be  seen  in  congeries  and  filled  with 
coagula.  The  brain  substance  was  softened  and  cedema- 
tous,  so  that  serum  followed  the  knife.  The  ventricles 
were  distended  with  serum.  Subsequent  microscopic  ex- 
amination of  the  brain  tissue  in  the  recent  state  disclosed 
no  inflammatory  changes.  There  was  an  extravasation  of 
blood  behind  the  peritoneum  on  the  right  side,  but  no  vis- 
ceral injury,  and  there  were  no  chronic  visceral  lesions. 

Case  XXV.  Symptouis. — vStupor;  hemorrhage  from 
right  ear ;  lack  of  control  of  urine  and  faeces ;  condition 
alcoholic;  second  day,  active  delirium,  muscular  tremor, 
delusions,  and  intervals  of  unconsciousness;  sixth  day, 
coma,  stertor,  muttering  delirium,  general  muscular  rigid- 
ity, slight  contraction  of  right  pupil,  and  slight  right  facial 
paralysis;  eighth  day,  two  slight  convulsions  involving 
arms,  face,  and  eyes,  followed  by  paralysis  of  right  arm 
and  face,  and  elevation  of  surface  temperature  of  left  side ; 
right  side  normal;  left  side,  102°,  Death  on  the  eighth 
day.  Temperature  till  fourth  day,  100°  to  102°;  afterward 
103°  to  104°  till  eighth  day,  when  it  rose  to  105.6°  and  de- 
clined to  104.8°,  with  post-mortem  elevation  to  106°. 

Lesions. — Thin  layer  of  pial  hemorrhage,  covering  both 
parietal  and  both  occipital  lobes,  and  meningeal  hyper- 
semia;  large  subarachnoid  serous  effusion ;  general  oedema 
of  brain  substance  and  minute  vessels  filled  with  coagula ; 
fluid  blood  in  anterior  cornu  of  left  lateral  ventricle ;  small 
lacerations  of  superior  and  external  surface  of  right  fron- 
tal and  of  left  occipital  lobes  and  on  either  side  of  median 
fissure  of  cerebellum.  Neither  laceration  was  larger  than 
a  walnut,  and  neither  involved  a  rupture  of  the  pia  mater. 
A  linear  fracture  was  confined  to  the  right  petrous  portion. 

Case  XXVI.  Symptoms. — Vertigo  and  feeling  of  ill- 
ness; wound  in  right  temporal  region.     On  admission  to 


CASES   VERIFIED    BY   NECROPSY.  409 

hospital,  entire  consciousness  and  mental  control;  hem- 
orrhage from  right  ear;  temperature,  100°;  soon  afterward 
profuse  hsematemesis,  coma,  and  stertor.  Death  in  four 
hours. 

Lesions. — Depressed  fracture  of  right  frontal  bone  one 
inch  from  median  line  and  just  anterior  to  coronal  suture, 
triangular  in  form,  with  apex  extending  to  superciliary 
ridge.  One  fissure,  originating  in  this  depression,  ran 
through,  right  orbital  plate,  and  greater  and  lesser  wings 
of  sphenoid,  into  middle  fossa;  another  ran  through  squa- 
mous into  petrous  portion  of  temporal  bone,  terminating 
upon  its  anterior  surface.  There  was  an  epidural  clot  ex- 
tending over  lateral  aspect  of  right  frontal  lobe  into  the 
middle  fossa.  This  portion  of  the  frontal  lobe  was  much 
flattened  and  compressed.  There  was  no  subdural  hemor- 
rhage and  no  superficial  laceration  of  the  brain.  There 
was  a  small  effusion  of  blood  in  the  meshes  of  the  pia  on 
either  side  of  the  medulla,  behind  the  pons,  parallel  to  the 
anterior  columns.  The  whole  brain  was  hypersemic  with 
a  multitude  of  punctate  extravasations,  and  the  minute 
vessels  were  filled  with  coagula.  Upon  section  a  number 
of  extravasations  were  found  in  the  substance  of  the  pons, 
mainly  in  the  transverse  fibres,  but  some  in  the  longitudi- 
nal fibres  of  the  crura.  The  smaller  ones  were  of  the  size 
of  a  robin  shot.  The  largest  one  was  one-half  inch  long  by 
one-fourth  of  an  inch  wide,  and  was  just  below  the  surface 
on  the  right  external  border  of  its  inferior  surface. 

Case  XXVII.  Symptoms. — Permanent  and  primary 
unconsciousness;  haematoma  at  vertex;  ecchymosis  at 
base,  right  side ;  slight  hemorrhage  from  right  nostril ; 
stertor;  pulse,  130,  irregular  and  weak;  temperature,  94°; 
rose  to  102°  some  hours  later;  both  eyes  protruded  and 
both  pupils  were  dilated,  left  pupil  most  markedly  so; 
some  rigidity  of  right  side.  Death  in  eight  to  ten  hours 
after  admission  into  the  hospital. 

Lesions. — Fracture  extending  from  right  posterior  fossa 
through  petrous  portion  into  middle  fossa.     Epidural  hem- 


4IO  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

orrhage  in  posterior  fossa;  small  laceration  of  inferior  sur- 
face of  left  prefrontal  lobe ;  thin  cortical  hemorrhage  over 
superior  surface  of  both  frontal  lobes.  Fracture  confined 
to  base. 

Case  XXVIII.  Symptoms. — Wound  in  right  parietal 
region;  temperature,  98.8°;  in  twenty  minutes  left  lower 
extremity  became  paretic.  On  the  fourth  day  temperature 
suddenly  rose  from  99°+  to  102°.  On  the  fifth  day,  de- 
lirium and  temperature  of  io5.2°-io6°.     Death. 

Lesions. — Fracture  extending  from  right  squamous  por- 
tion through  both  anterior  fossae,  involving  right  greater 
sphenoid  wing  and  both  orbital  plates.  Laceration  of  in- 
ferior surface  of  left  temporal  lobe,  and  consequent  corti- 
cal hemorrhage  filling  left  middle  fossa. 

Case  XXIX.  Symptoms. — Wound  in  left  inferior  tem- 
poral region,  fracture  of  left  malar  bone,  and  contusions 
of  face.  Coma,  moist  bronchial  rales,  dilatation  of 
right  pupil,  left  invisible  from  ecch3'mosis,  anaesthesia  fol- 
lowed by  paralysis  of  right  upper  extremity ;  temperature, 
101.6'^.  Three  hours  later,  patient  apparently  mori- 
bund. Second  day:  mental  condition  normal;  motor  and 
sensory  functions  restored,  urinary  control  lost;  pupils 
normal;  temperature,  99°+.  Fifth  day:  temperature 
had  gradually  increased  to  103°  and  some  subconjunctival 
hemorrhage  had  become  evident.  Sixth  and  seventh 
days:  mental  condition  apathetic,  and  subconjunctival 
hemorrhage  increased;  temperature  had  declined  to  100°. 
Eighth  day:  sudden  loss  of  consciousness;  tempera- 
ture, 104.8°  with  decline  in  two  hours  to  102.8°,  gradual 
decreasing  strength.  Death  on  the  ninth  day ;  temperature, 
106°,  with  immediate  post-mortem  recession. 

Lesions. — An  open  fissure,  through  both  tables  of  bone, 
extended  from  a  point  just  to  the  left  of  the  occipital  tuber 
to  the  left  foramen  lacerum  posterius.  Moderate  subarach- 
noid serous  effusion ;  subcortical  lacerations,  which  disinte- 
grated and  filled  with  clot  the  whole  interior  of  both 
frontal  lobes.     On  the  left  side  the  median  surface  was 


CASES   VERIFIED    BY   NECROPSY.  4II 

ruptured  through  the  arm  centre  and  gyrus  fornicatus,  and 
the  lateral  ventricle  was  invaded ;  the  clot  was  very  solid 
and  the  external  layers  of  fibrin  on  its  inferior  aspect  were 
partially  decolorized.  On  the  right  side  the  clot  was  of 
equal  size,  but  had  not  broken  through  the  cortex  or  into 
the  lateral  ventricle.  There  was  no  cortical  hemorrhage, 
though  the  posterior  border  of  the  left  cerebellar  lobe  was 
deeply  lacerated.  The  brain  substance  was  softened  and 
reddened  in  patches  of  limited  contusion. 

Case  XXX.  Symptoms. — Small  wound  in  left  posterior 
parietal  region.  Permanent  unconsciousness ;  slight  hem- 
orrhage from  both  nostrils;  left  pupil  dilated,  right  pupil 
contracted;  loss  of  faecal  and  urinary  control;  face  flushed. 
Temperature,  ioi°,  and  on  the  second  day  ioi°-l-;  then 
rose  progressively  to  106.8°  at  death,  in  three  and  one- 
half  days,  with  post-mortem  increase  to  109"^.  On  the 
last  day  general  sensation  obviously  diminished. 

Lesions. — Fine  fissure  extended  from  left  of  occipital 
protuberance  through  posterior  fossa  and  petrous  portion 
to  foramen  ovale.  Laceration  excavating  inferior  surface 
of  right  frontal,  and  extending  into  right  temporal  lobe; 
laceration  of  middle  portion  of  left  gyrus  fornicatus,  one- 
half  inch  in  diameter;  wide  and  deep  laceration  across 
inferior  surface  of  left  cerebellar  lobe.  The  laceration  of 
the  gyrus  fornicatus  involved  the  cortex.  Cortical  hem- 
orrhages; clot,  three  fluid  ounces  by  measurement,  in 
anterior  fossse;  hemorrhage  slight  in  right  posterior 
fossa,  and  in  moderate  amount  over  lateral  surface  of 
right  frontal  lobe;  all  resulted  from  these  several  lacer- 
ations. General  contusion  of  both  hemispheres,  most 
marked  posteriorly. 

Case  XXXI.  Symptoms. — Brief  unconsciousness,  which 
recurred  in  the  ambulance ;  in  the  interval  no  evidence  of 
serious  injury.  On  admission  to  the  hospital,  pupils  con- 
tracted, sudden  cyanosis,  and  death  in  twenty-five  min- 
utes. 

Lesions. — Haematoma  in  left  occipital  region ;  blood  still 


412 


INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 


fluid.  Stellate  fracture,  with  centre  in  left  upper  occipital 
region,  and  with  fissures  running  downward  into  foramen 
maofnum,  forward  and  downward  into  middle  fossa,  and 
upward  and  laterally.  Epidural  clot  in  left  occipital  re- 
gion ;  pial  hemorrhage  in  inferior  occipital  fossae  over 
pons  and  medulla;  and  cortical  hemorrhage  over  both 
frontal  and  both  temporal  lobes  from  laceration  of  their 
inferior  surfaces. 

Case  XXXII,     Symptoms. — Patient  injured  by  the  fall 
of  a  brick  from  the  fourth  story  of  a  building ;  admitted  to 


/ 


/ 


Fig.  42.— External  Surface  of  Calvarium  at  Point  of  Fracture.    A,  Trephine  opening; 
B.  portion  of  lambdoid  suture;  C,  masto-parietal  suture. 


the  hospital  on  the  second  day ;  mind  clear ;  hemorrhage 
from  the  right  ear;  compound  comminuted,  depressed, 
fracture  in  the  right  supramastoid  region ;  trephination  and 
elevation  of  bone ;  dura  mater  uninjured  ;  primary  union 
of    wound,    and    cicatrization    of   drainage    exit    without 


CASES   VERIFIED    BY   NECROPSY. 


413 


formation  of  pus.  Hemorrhage  from  ear  ceased,  and 
during  first  week  no  general  symptoms;  temperature  fall- 
ing from  100.4°  to  normal.  On  the  eighth  day,  tem- 
perature rose  to  101.4°,  and  an  enlarged  and  painful 
lymphatic  gland  was  discovered  in  right  posterior  cer- 
vical triangle.  On  the  seventeenth  day,  no  symptoms, 
general  or  local;  temperature  normal.     On  the  twentieth 


L 


r' 


Fig.  43. — Internal  Surface  of  Calvariuin  at  Point  of  Fracture.     A^  Trephine  opening; 
B^  C,  portions  of  internal  table  slightly  depressed. 

day,  some  malaise  and  headache,  the  apparent  result  of  a 
surreptitious  bottle  of  red  wine.  On  the  twenty-third  day, 
severe  frontal  headache,  delirium,  somnolence,  and  left 
hemiplegia.  On  the  twenty-fourth  day,  complete  left  hemi- 
plegia and  hemiansesthesia,  continued  somnolence,  and 
sluggish  movement  of  the  pupils;  left  eye  injected;  tem- 
perature, 98.5°;  pulse,  6(i;  cicatrix  uninflamed.  On  the 
twenty-fifth  day,  increasing  stupor  and  loss  of  faecal  and 


414 


INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 


urinary  control;  temperature,  100.2°.  The  wound  was 
then  reopened,  and  the  dura,  which  was  pulsating,  was 
incised ;  the  cerebral  surface  was  of  normal  consistence 
and  had  been  uninjured.  A  subcortical  abscess  was  dis- 
covered by  exploration  at  the  first  insertion  of  the  probe, 
from  which  one  to  two  drachms  of  reddish  pus  and  dis- 
integrated brain  tissue  were  evacuated.     During  the  oper- 


FlG.  44. — Section  of  the  Brain  Showing  Abscess  Cavity  and  Area  of  Softening. 
A,  Abscess  cavity;  B,  area  of  softening  gradually  disappearing  at  E ,  C,  section  of 
convulution  of  central  lobe  (island  of  Reil);  D,  section  of  lateral  ventricle. 

ation  respiration  failed,  and  was  restored  only  by  trache- 
otomy; reaction  was  complete.  Temperature  rose  to  108°, 
and  death  occurred  sixteen  hours  later. 

Lesions. — The  fracture  involved  the  right  parietal  and 
occipital  bones ;  the  disc  which  had  been  elevated  was  two 
inches  by  one  and  one-half  inches  in  its  principal  diameters, 
included  the  outer  half  of  the  lambdoid  suture,  and  was 
continuous  with  a  fissure  which  was  prolonged  through 
the  whole  anterior  surface  of  the  petrous  portion.  There 
was  no  intracranial  hemorrhage,  no  subarachnoid  effusion 
or  arachnoid  opacity,  and  no  superficial  contusion  or  lacer- 
ation. The  dura  mater  and  pia  mater  were  adherent  to  each 
other  over  a  small  area  in  the  posterior  and  inferior  part 
of  the  parietal  lobe  on  the  right  side  corresponding  in  sit- 
uation to  the  site  of  fracture.  In  this  area  the  meshes  of 
the  pia  mater  were  infiltrated  with  blood,  and  beneath  it 


CASES   VERIFIED    BY    NECROPSY.  415 

was  an  area  of  softening  which  extended  forward  for  about 
two  and  one-fourth  inches.  The  brain  was  hardened  in 
alcohol,  and  an  oblique  longitudinal  section  then  made  in 
a  plane  passing  downward  and  inward,  which  intersected 
the  abscess  cavity ;  this  was  found  to  communicate,  through 
a  canal  made  by  the  passage  of  the  probe  during  life, 
with  the  surface  at  the  point  where  the  adhesions  be- 
tween the  membranes  were  firmest.  At  this  point  the  ab- 
scess cavity  Avas  most  superficial,  but  was  at  least  three- 
eighths  of  an  inch  distant  from  the  surface.  The  abscess 
had  a  well-defined  wall,  and  broadened  as  it  extended 
forward  and  inward  toward  the  median  line  for  a  distance 
of  about  seven-eighths  of  an  inch.  It  was  surrounded 
by  a  wide  area  of  softening,  which  in  the  part  lying  be- 
tween it  and  the  surface  at  the  site  of  the  meningeal 
adhesions  was  slightly  hemorrhagic  and  seemed  to  date 
from  an  earlier  period  than  elsewhere.  In  front  of  the 
abscess  cavity  the  softening  extended  above  and  below 
the  convolutions  of  the  island  of  Reil,  and  cut  the  motor 
and  sensory  fibres  both  before  and  after  their  passage 
through  the  internal  capsule. 

Case  XXXIII.  Symptoms. — Unconsciousness,  which 
continued  till  death ;  hemorrhage  from  left  ear ;  dilatation 
of  both  pupils,  and  subsequent  contraction  of  right; 
muscular  relaxation,  followed  by  later  rigidity;  temper- 
ature on  admission,  99.6°;  afterward,  99.6°  to  100.4°;  on© 
hour  post  mortem,  101.2°.     Death  in  twelve  hours. 

Lesions. — Wound  in  left  posterior  parietal  region. 
Semicircular  fracture  of  squamous  portion  of  left  temporal 
bone,  with  fissure  extending  into  anterior  surface  of  pe- 
trous portion ;  deep,  :well-defined  laceration,  laterally  and 
posteriorly,  of  left  temporo-sphenoidal  lobe,  from  which  a 
thick  clot  extended  over  occipital  region ;  brain  in  all 
its  parts  excessively  hyperasmic;  on  section,  the  surface 
was  repeatedly  bathed  in  blood  as  it  was  each  time  wiped 
away;  no  punctate  extravasation  or  coagula  in  minute 
vessels. 


4l6  INJURIES    OF    THE    BRAIN   AND    MEMBRANES. 

Case  XXXIV.  Symptoms. — Coma;  stertor;  loss  of 
urinary  control;  hemorrhage  from  nose  and  later  haema- 
temesis;  pulse,  96  and  full;  respiration,  18;  tem- 
perature, 100°,  rising  gradually  to  102.6°  some  time 
before  death,  in  fourteen  hours  after  admission  to  the 
hospital. 

Lesions. — Small  epidural  hemorrhage  at  site  of  fracture; 
rupture  of  dura  mater;  corresponding  laceration  in  anterior 
inferior  parietal  region ;  laceration  of  anterior  half  of  right 
middle  temporal  convolution ;  small  laceration  in  centre  of 
left  cerebellum  filled  with  fluid  blood;  general  hyperaemia, 
most  marked  on  left  side  posteriorly.  Wound  in  right 
occipito-parietal  region,  and  linear  fracture  in  right  parie- 
tal bone  extending  through  greater  wing  of  sphenoid  bone 
into  middle  fossa. 

Case  XXXV.  Symptoms. — Unconsciousness:  contrac- 
tion of  both  pupils;  rigidity  of  both  lower  and  of  right 
upper  extremities;  pulse  and  respiration  too  rapid  to  be 
counted;  temperature,  101°,  and  /;/  articulo  mortis  100.4°. 
Death  in  two  hours.  Temperature  two  hours  post  mor- 
tem, 99°+. 

Lesions. — Extravasation  of  blood  over  whole  left  parie- 
tal region,  not  evident  during  life;  separation  of  left  coro- 
nal suture  beginning  in  its  middle  portion,  with  a  continu- 
ous fissure,  which  in  left  middle  fossa  bifurcated  and 
terminated  in  greater  wing  of  the  sphenoid  and  at 
petro-mastoid  junction.  No  epidural  hemorrhage,  and  no 
superficial  laceration.  Pial  hemorrhage  over  left  frontal 
and  parietal  lobes  upon  their  superior  and  lateral  surfaces, 
and  about  the  region  of  right  occipito-parietal  junction ; 
small  central  laceration  of  left  corpus  striatum  at  junction 
of  middle  and  posterior  thirds;  excessive  general  hyper- 
aemia. 

Case  XXXVI.  Symptoms. — Coma;  stertor;  alcoholic 
condition;  no  superficial  injury ;  muscular  relaxation  ;  face 
flushed;  pupils  slightly  contracted;  vomiting;  temper- 
ature,    97°,    continuing    subnormal;    pulse,    60;    respira- 


CASES    VERIFIED    BY    NECROPSY.  417 

tion,  16;  one  general  convulsion  just  before  death,  at  the 
end  of  eight  hours  and  a  half. 

Lesions. — Fracture  through  left  occipital,  parietal,  and 
squamous  portion  of  temporal  bone  to  margin  of  petrous 
portion ;  laceration  of  inferior  surface  of  right  frontal  lobe 
and  of  both  temporo-sphenoidal  lobes;  pial  hemorrhage 
over  whole  right  parietal  region. 

Case  XXXVII.  Symptoms. — Patient  in  alcoholic  con- 
dition at  the  time  of  injury.  Primary  and  permanent  un- 
consciousness ;  stertor ;  left  radial  pulsations  fuller  and 
stronger  than  right;  compound  linear  fracture  in  left 
parietal  region,  through  which  blood  oozed  in  large 
amount  at  each  cardiac  contraction.  On  admission  to  hos- 
pital, temperature,  98°;  pulse,  100;  respiration,  32.  One 
and  one-half  hours  later,  temperature,  96°;  pulse,  iio; 
respiration,  40.     Death  in  three  hours. 

Lesions. — Fracture  extending  from  left  parietal  emi- 
nence into  left  middle  fossa,  and  terminating  just  be- 
hind foramen  spinosum ;  epidural  hemorrhage  along  the 
course  of  the  fracture;  small  pial  hemorrhage  over  left 
hemisphere ;  general  cerebral  hyperasmia.  The  epidural 
hemorrhage  was  derived  from  the  posterior  branch  of  the 
middle  meningeal  artery  and  the  blood  in  great  part  es- 
caped through  the  external  wound  during  life. 

Case  XXXVIII.  Symptoms. — The  patient,  after  hav- 
ing passed  through  three  hospitals,  with  three  discharges 
and  two  transfers,  and  after  having  wandered  about  the 
streets  and  suffered  much  exposure,  was  finally  received 
and  allowed  to  remain  in  an  asylum  for  the  insane  on  the 
eighth  day  after  a  fall  from  the  stoop  of  her  house.  She 
had  then  delusions  and  other  symptoms  of  mental  derange- 
ment, left  facial  paralysis,  left  subconjunctival  hemor- 
rhage, and  hemorrhage  from  both  ears.  She  died  on  the 
twenty-fourth  day  from  the  reception  of  the  injury. 

Lesions. — Transverse  fracture  of  the  base,  extending 
through  both  petrous  portions  and  left  orbital  plate ;  lac- 
eration of  inferior  surface  of  left  frontal  lobe ;  small  sub- 
27 


41 8  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

cortical  laceration  of  left  parietal  lobe ;  cortical  liemor- 
rhasfe  at  base  and  over  external  surface  of  both  hemi- 
spheres;  general  contusion. 

Case  XXXIX.  Symptoms. — Profound  coma,  which 
continued  till  death;  stertor;  pulse,  70,  full  and  strong; 
temperature,  99.4°.     Death  in  seven  hours. 

Lesions. — Linear  fracture  through  right  side  of  oc- 
cipital bone  to  jugular  foramen;  pial  hemorrhage  over 
both  occipital  lobes  and  posterior  portion  of  left  parietal 
lobe ;  excessive  general  hyperaemia. 

Case  XL.  Symptoms. — Contusion  of  left  parietal  re- 
gion; primary  unconsciousness;  epistaxis;  delirium,  which 
continued  till  admission  to  hospital  two  days  later;  uncon- 
sciousness at  that  time ;  pupils  normal ;  pulse  rapid  and 
weak;  respiration,  21 ;  temperature,  101.4°,  rising  to  102°-}-; 
consciousness  not  restored.     Death  in  four  days. 

Lesions. — Linear  fracture  of  occipital  bone  from  tuber 
to  right  jugular  foramen ;  also  fissure  of  left  orbital 
plate;  thrombosis  of  lateral  sinuses;  clot  firm,  but 
not  decolorized ;  general  cerebral  hyperaemia,  with  a  few 
minute  coagula. 

Case  XLL  Symptoms. — Unconsciousness  succeeding 
an  injury  received  on  the  preceding  day;  admission  to 
hospital  after  twenty-four  hours ;  right  pupil  slightly  di- 
lated; temperature,  99.8°;  pulse,  96;  respiration,  24;  tem- 
perature rose  to  100,2°.  Death  in  about  thirty  hours  from 
time  of  injury. 

Lesions. — Linear  fracture  running  nearly  transversely 
through  left  parietal  bone  into  right  coronal  suture ;  also 
V-shaped  indirect  fracture  in  right  middle  fossa;  epidural 
hemorrhage  over  right  frontal  lobe  from  vertex  to  base; 
laceration  of  middle  two-fourths  of  second  right  temporal 
convolution,  with  cortical  hemorrhage  extending  over  pa- 
rietal lobe;  general  hyperaemia  with  minute  coagula  in  all 
parts  of  the  brain. 

Case  XLIL  Symptoms. — Shock;  consciousness  re- 
tained; temperature,  96°;  pulse,  78;  respiration,  21;  sud- 


CASES   VERIFIED    BY   NECROPSY.  419 

den  cyanosis,  with  extreme  dyspnoea,  and  loss  of  conscious- 
ness, which  lasted  for  only  three  or  four  minutes,  followed 
by  numbness  of  both  arms;  no  further  dyspnoea;  deliri- 
um fourteen  hours  later,  and  death  four  hours  later  still, 
preceded  by  a  single  convulsive  movement  and  without 
respiratory  disturbance. 

Lesions. — Occipital  contusion  and  wound  behind  right 
ear;  bifurcated  linear  fracture  in  right  inferior  occipital 
fossa;  pial  hemorrhage  beneath  tentorium,  extending 
around  lateral  borders  of  cerebellum  and  covering  the 
pons;  moderate  general  hyperaemia. 

Case  XLIII.  Symptoms. — Scalp  wounds  in  left  parietal, 
and  large  haematoma  in  right  parietal  region ;  compound 
linear  left  parietal  fracture;  no  known  loss  of  conscious- 
ness ;  shock ;  dilatation  of  both  pupils ;  pulse  feeble ;  res- 
piration shallow;  temperature  after  four  hours,  96.4°. 
Death  in  nine  hours  and  a  half. 

Lesions. — Parietal  fissure  extended  nearly  across  greater 
wing  of  sphenoid ;  considerable  subarachnoid  serous  effu- 
sion ;  general  hypersemia  and  thrombosis  of  minute  ves- 
sels, most  marked  posteriorly. 

Case  XLIV.  Symptoms. — Unconsciousness  till  death ; 
pupils  normal;  muscular  twitchings  over  whole  right  side 
of  body;  temperature  on  admission,  98°;  in  six  hours, 
103.6°;  in  seven  hours,  104.4°;  in  nine  hours,  106.6°; 
pulse,  80  to  145;  respiration,  15  to  34,  Death  in  nine 
hours  and  a  half. 

Lesions. — Calvarium  crushed ;  large  wound  in  the  skull 
at  the  vertex  involving  the  median  line,  two  by  three  inches 
in  its  diameters;  on  the  left  side  the  osseous  fragments 
rested  upon  the  dura  mater,  on  the  right  they  deeply  pen- 
etrated the  brain;  a  fissure  extended  into  the  right  orbital 
plate;  epidural  clot  on  the  left  side,  in  which  the  parietal 
fragments  were  embedded ;  on  the  right  side,  disintegrated 
brain  tissue,  bone,  and  membranes  were  commingled ;  an- 
terior part  of  both  lateral  ventricles  contained  blood  ;  cor- 
tical hemorrhage  extended  beneath  the  tentorium ;  general 


420  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

hyperasmia  and  vessels  even  of  the  larger  size  filled  with 
thrombi. 

Case  XLV.  Symptoms. — Scalp  wound  in  left  frontal 
region ;  left  pupil  dilated ;  consciousness  only  partially 
lost;  temperature  on  admission,  98°;  fell  in  four  hours  to 
97.6°;  pulse,  90;  respiration,  24.  Death  in  four  hours  and 
a  half. 

Lesions. — Slight  depression  at  left  external  angular 
process  of  frontal  bone,  and  fissure  extending  thence 
through  both  orbital  plates  and  intervening  ethmoid  body ; 
deep  laceration  of  frontal  lobes  on  either  side  of  inferior 
median  fissure ;  smaller  laceration  of  posterior  border  of 
cerebellum,  near  median  line,  from  which  a  cortical  hem- 
orrhage extended  over  both  its  superior  and  inferior  sur- 
faces; general  hyperaemia  and  minute  coagula. 

Case  XLVI.  Symptoms. — Haematoma  over  whole  ver- 
tex, and  small  wound  of  scalp;  unconsciousness,  which 
continued  till  death ;  dilatation  of  left  pupil ;  general  con- 
vulsions, beginning  in  hands,  with  marked  opisthoto- 
nos; temperature  six  hours  after  reception  of  injury,  98.6° ; 
pulse,  84;  respiration,  28;  extent  of  fracture  determined 
by  incision.     Death  in  nine  hours. 

Lesions. — Disjunction  of  coronal  suture,  multiple  fis- 
sure of  frontal  bone,  and  fissure  through  right  parietal 
and  occipital  bones,  with  branch  into  posterior  fossa ;  lacer- 
ation of  right  frontal,  parietal,  and  occipital  lobes,  and 
wound  of  dura  mater  permitting  escape  of  brain  tissue 
through  osseous  parietal  opening. 

Case  XLVI  I.  Symptoms. — Contusions  of  left  side  of 
head  and  face,  and  tactile  evidence  of  simple  fractures; 
unconsciousness,  which  continued  till  death ;  epistaxis  and 
hsematemesis ;  temperature  on  admission,  99°;  pulse,  96; 
two  hours  later,  temperature,  96.4°;  pulse,  140;  respiration, 
53;  five  hours  later,  temperature,  95.6°;  pulse  and  res- 
piration as  before.  Second  day,  deglutition  became  possi- 
ble and  sensitiveness  to  external  impressions  was  regained; 
pupils  slightly  dilated ;  temperature,  103°  to  103.6°;  pulse, 


CASES   VERIFIED    BY    NECROPSY.  42 1 

168  to  196;  respiration,  48  to  58.  Death  in  thirty-four 
hours.  (In  this,  the  case  of  a  child  four  years  and  a  half 
of  age,  the  brain  weighed  forty-eight  ounces,  and  was  in 
all  respects  symmetrical ;  the  skull  was  of  normal  thick- 
ness.) 

Lesions. — Separation  of  the  coronal  and  of  the  bifrontal 
suture  to  nasal  bones,  which  were  fractured ;  fracture  con- 
tinuous into  ethmoid  body,  with  complete  detachment  of 
the  crista  galli  and  cribriform  plate ;  fissure  of  right  parie- 
tal bone  and  depressed  fracture  of  left  frontal  above  orbital 
ridge ;  slight  epidural  hemorrhage  over  vertex ;  lacer- 
ation of  frontal  lobes  in  the  space  corresponding  to  the 
site  of  cribriform  plate ;  general  hypersemia  with  minute 
coagula,  most  marked  in  cerebellum  and  occipital  lobes. 

Case  XLVIII.  Symptoms. — None  discovered,  and  ad- 
mission to  hospital  refused  two  days  after  a  fall  in  the 
street;  found  dead  two  hours  later  a  block  away ;  wound 
over  left  eye. 

Lesions. — Pneumonia  involving  lower  lobe  of  right 
lung,  and  large  flabby  heart ;  fracture  extending  through 
left  supra-orbital  ridge  and  orbital  plate  into  greater  wing 
of  sphenoid  bone ;  general  hypersemia  and  thrombosis. 

Case  XLIX.  Symptoms. — Large  hsematoma  over  right 
eye;  profuse  hemorrhage  from  mouth,  nose,  and  right  ear; 
unconsciousness;  rapid  and  feeble  pulse  and  respiration ; 
dilatation  of  both  pupils,  especially  the  left.  Death  in  fif- 
teen minutes.  (Caesarean  section  at  six  months  and  a  half ; 
child  lived  forty-five  minutes.) 

Lesions. — Separation  of  right  sutura  additamentum  lamb- 
doidalis  and  fissure  continued,  through  petrous  portion  and 
middle  fossa,  into  body  of  sphenoid  bone ;  large  pial  hem- 
orrhage over  left  parieto-occipital  region. 

Case  L.  Symptoms. — Wound  over  left  eye  and  at 
occiput;  shock;  unconsciousness;  hemorrhage  from  ears, 
nose,  and  mouth;  restlessness,  and  utterance  of  short, 
sharp  cries;  pulse  frequent,  weak,  and  symmetrical;  respi- 
ration slow,  irregular,  and  sighing;  right  pupil  dilated,  and 


422  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

left  invisible  from  ecchymosis,  twitching  of  right  side  of 
face,  followed  by  general  convulsions,  preceded  death  at 
end  of  twelve  hours. 

Lesions,  discovered  by  incisions:  In  left  temporal  region 
fissures  ran  into  temporal  fossa,  and  squamous  suture  was 
partially  disrupted;  in  occipital  region  open  fissure  ran 
into  right  petrous  portion  and  lambdoid  suture  was  sepa- 
rated; arachnoid  hemorrhage  in  right  occipito-parietal 
region. 

Case  LI.  Symptoms. — Scalp  wounds  in  parietal 
regions;  mobility  and  crepitation  of  calvarium;  shock; 
unconsciousness,  which  continued  till  death ;  slight  epis- 
taxis  and  profuse  haematemesis ;  both  pupils  dilated,  and 
after  three  hours  and  a  half  the  right  more  so  than  the 
left ;  one  radial  pulse  fuller  and  stronger  than  the  other ; 
temperature  on  admission,  ioi°;  in  one  hour,  102°;  in  two 
hours,  106°;  in  four  hours,  106.8°;  pulse,  70,  no,  160, 
170;  respiration  in  two  hours,  48.  Death  in  four  hours 
and  a  half. 

Lesions. — Fissure,  beginning  just  above  left  internal 
angular  process,  running  across  middle  of  parietal  bones, 
and  nearly  circumscribing  calvarium ;  another  detached 
its  posterior  portion,  and  others  still  extended  from 
primary  line  of  fracture  to  base;  arachnoid  hemorrhage 
on  left  side;  further  examination  refused. 

Case  LII.  Symptoms. — Contusion  in  left  frontal  region 
and  ecchymosis  of  left  eye;  consciousness  retained;  hem- 
orrhage from  right  ear  and  from  nose  and  mouth;  de- 
lirium, becoming  violent  later  in  the  day  and  during  the 
night.  On  the  second  day,  the  patient  formed  a  fixed  delu- 
sion that  he  had  fallen  from  a  mulberry  tree.  He  de- 
scribed with  circumstantiality  all  the  details  of  his  imagi- 
nary accident.  He  had  no  recollection  of  the  manner  in 
which  his  injury  had  really  occurred,  and  would  give  no 
credence  to  facts  as  they  were  presented  to  him ;  he  had 
other  and  transitory  delusions,  but  this  one  remained  un- 
alterable.    Both  pupils  were  moderately  and  symmetrically 


CASES   VERIFIED    BY   NECROPSY.  423 

dilated.  His  mind  became  remarkably  alert,  and  his  con- 
versation was  logical  and  coherent.  Nine  days  later  hem- 
orrhage from  the  right  ear  recurred;  subconjunctival 
hemorrhage,  which  had  been  previously  noted,  increased, 
and  the  left  eye  became  prominent.  Mechanical  restraint 
was  still  necessary  to  keep  him  in  bed.  On  the  twelfth 
day,  hemorrhage  from  the  ear  ceased,  and  subconjunctival 
hemorrhage  diminished ;  a  scarcely  perceptible  facial 
paralysis  existed.  His  mind  seemed  clearer;  he  could 
recollect  the  street  and  neighborhood  in  which  he  lived, 
but  not  the  number  of  his  house ;  only  the  one  delusion 
persisted.  Later,  a  frontal  headache  from  which  he  had 
constantly  suffered  became  less  urgent ;  but  his  general 
condition  was  not  materially  changed  till  two  days  before 
his  death,  when  he  became  progressively  asthenic  from  an 
intercurrent  diarrhoea.  His  mind  remained  clear  with 
occasional  transient  delusions,  his  conversation  coherent, 
and  his  belief  in  the  mulberry  tree  unshaken  to  the  last. 
Temperature  on  admission  was  98.6°;  one  hour  later,  100°; 
and  five  hours  later,  104.7°;  for  the  two  days  following  it 
was  103°  to  103.8°;  and  during  the  fourth  and  fifth  days, 
101°  to  99°+  ;  it  varied  till  the  twentieth  day  from  99.8° 
to  101.8°,  only  twice  exceeding  100°.  The  pulse  on  ad- 
mission was  85,  and  the  respiration  20,  with  no  considera- 
ble subsequent  changes  till  near  the  close  of  life.  Thirty- 
six  hours  ante  mortem  temperature  rose  to  102.4°,  a-^id 
twelve  hours  later  to  105°;  in  another  twelve  hours  it  de- 
clined to  97.5°,  and  immediately  before  death  rose  again  to 
100°,  with  pulse  of  140,  and  respiration  of  42.  Death  on 
the  twenty-fourth  day. 

Lesions.  —  Depressed  fracture  above  left  supra-orbital 
ridge,  with  fissure  extending  across  both  orbital  plates  and 
intervening  cribriform  plate,  through  right  middle  fossa, 
external  to  greater  wing  of  sphenoid,  through  outer  part 
of  petrous  portion  of  temporal  into  posterior  fossa,  and 
returning  upon  itself  across  petrous  portion  and  through 
body  of  sphenoid  and  ethmoid  finally  to  terminate  in  itself 


424  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

anteriorly.  A  second  fissure  crossed  left  orbital  plate  into 
left  middle  fossa.  Small  epidural  hemorrhage  beneath  de- 
pressed part  of  fracture ;  laceration  of  under  surface  of 
both  frontal  lobes,  mainly  subcortical,  crossing  median 
line  obliquely  from  centre  of  left  lobe  to  line  of  right  an- 
terior cerebral  artery.  This  laceration  was  one  inch  and 
one  fourth  wide  by  one  inch  in  depth  at  its  commencement 
on  the  left  side,  and  on  the  right  side  was  five-eighths  of 
an  inch  in  width  by  half  an  inch  in  depth.  In  removing 
the  brain  the  arachnoid  was  torn  and  the  difiluent  contents 
of  the  cavity  escaped;  its  margin  and  the  overhanging  cor- 
tical tissue  were  dark  and  sloughy ;  its  deeper  portion  was 
yellow  and  ragged;  it  was  separated  anteriorly  on  the 
left  side  from  the  median  fissure  by  a  single  convolution. 
There  were  general  hj'peraemia  and  minute  thromboses, 
most  marked  posteriorly. 

Case  LIII.  Symptoms. — Haematoma  in  left  parietal 
region ;  coma ;  stertor ;  no  response  to  external  irritation  ; 
pupils  widely  dilated;  pulse  full,  slow,  and  strong;  tem- 
perature on  admission,  99°,  and  rose  steadily  to  107.8°; 
respiration,  32,  46,  14;  pulse,  62,  70,  126.  Death  in  four 
hours  and  three-quarters. 

Lesions. — Coronal  suture  separated  and  fracture  contin- 
ued into  anterior  part  of  middle  fossa  on  both  sides;  gen- 
eral hypersemia  with  well-marked  but  not  excessive 
oedema,  and  some  punctate  extravasations. 

Case  LIV.  Symptoms. — Consciousness  lost,  but  par- 
tially restored  on  arrival  of  ambulance ;  large  haematoma 
in  right  posterior  occipital  region;  slight  epistaxis;  pupils 
moderately  contracted ;  respiration  shallow ;  right  radial 
pulse  after  two  hours  more  frequent  than  the  left — 84  and 
74,  114  and  no;  temperature  on  admission,  96'';  in  two 
hours,  95°;  in  six  hours  normal,  rising  to  100.4°  before 
death  in  nine  hours. 

Lesions. — Separation  of  coronal  suture  on  left  side  and 
fracture  continued  through  middle  fossa,  sella  turcica, 
right  middle  fossa,   right  petrous  portion,   and    posterior 


CASES    VERIFIED    BY    NECROPSY.  425 

fossa,  to  foramen  magnum ;  large  epidural  clot  in  left 
temporal  region ;  slight  cerebral  oedema ;  old  meningeal 
adhesions,  and  small  white  nodules  in  the  pia  mater. 

Case  LV.  Symptoms.- — Consciousness  retained  for  fif- 
teen minutes  after  admission ;  then  delirious  four  hours ; 
afterward  consciousness  lost;  contusion  of  right  side  of 
head;  hemorrhage  from  left  ear  and  nose,  and  ha^ma- 
temesis ;  slight  dilatation  of  right  pupil ;  temperature  on 
admission,  101°,  rising  to  103°;  pulse,  90  to  108;  respi- 
ration, 22,  24.     Death  in  ten  hours. 

Lesions. — Linear  fracture  extended  from  right  squa- 
mous portion  through  body  of  sphenoid  and  both  middle 
fossse  into  left  petrous  portion ;  a  second  fissure  extended 
from  sphenoid  into  cribriform  plate ;  large  epidural  clot  in 
left  middle  fossa;  marked  general  hyperaemia. 

Case  LVI.  Symptoms. — Delirium,  which  continued 
till  final  unconsciousness  at  close  of  life ;  wound  in  left 
temporal  region ;  hemorrhage  from  right  ear;  second  day, 
paralysis  of  left  arm ;  fourth  day,  loss  of  control  of  urine 
and  faeces;  death  in  three  days  and  eight  hours.  Tem- 
perature on  admission,  99°-)-;  rose  to  103.2°,  declined  to 
101°,  and  rose  to  106.6°  shortly  before  death;  pulse,  90 
to  114;  respiration,  18  to  28. 

Lesions. — Linear  fracture  extending  from  outer  part  of 
right  petrous  portion,  through  body  of  sphenoid  bone  into 
its  left  lesser  wing;  epidural  hemorrhage  in  left  middle 
fossa;  large  pial  hemorrhage  over  right  temporal  and 
parietal  lobes,  especially  profuse  near  the  vertex;  general 
hyperaemia  with  minute  coagula ;  thrombus  in  each  lateral 
sinus. 

Case  LVII.  Symptoms. — Consciousness  lost,  partially 
recovered  after  admission;  articulation  imperfect;  alco- 
holic condition ;  small  wound  in  right  occipital  region ; 
active  delirium  a  few  hours  later;  alternations  of  delirium 
and  stupor  till  death,  sixteen  days  afterward;  temperature, 
pulse,  and  respiration  normal  from  second  to  fourth  day; 
temperature  varied  from  99.4°  to   104.8',  and  was   103°  at 


426  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

time  of  last  observation;    pulse,    112  to   144;    respiration, 
26  to  44. 

Lesions. — Fracture  extending  from  right  of  foramen 
magnum,  three  inches  and  a  half,  into  left  inferior  oc- 
cipital fossa ;  laceration  of  inferior  surface  of  both  frontal 
and  left  temporo-sphenoidal  lobes;  pial  hemorrhage  over 
right  occipital  lobe;  general  subarachnoid  serous  effusion. 

Case  LVIII.  Symptoms. — Coma,  which  lasted  for  a 
few  hours ;  wound  in  occipital  region ;  no  general  symp- 
toms noted  till  seventh  day,  when  sudden  recurrence  of 
coma  was  followed  by  death.  Temperature  second,  third, 
and  fourth  days,  100.4°  to  99.4°;  after  second  coma,  104;° 
pulse  and  respiration  normal. 

Lesions. — Fracture  through  right  middle  fossa,  involv- 
ing petrous  portion ;  laceration  of  inferior  surface  of  right 
frontal  and  temporo-sphenoidal  lobes;  cortical  hemor- 
rhage over  almost  entire  surface  of  right  cerebrum ;  clot 
in  substance  of  right  centrum  ovale. 

Case  LIX.  Symptoms. — Momentary  unconsciousness; 
contusion  of  left  eye  and  wound  of  left  frontal  region ; 
epistaxis  without  perceptible  injury  of  the  nose ;  second 
day,  delirium  at  intervals,  becoming  constant  through  the 
night;  third  day,  somnolence,  restlessness,  and  deliriiim 
characterized  by  delusions ;  at  close  of  the  fourth  day  delir- 
ium became  muttering  and  respiration  stertorous.  Death 
in  four  days  and  a  half.  Temperature  on  admission, 
99.8°;  on  the  second  day,  104.8°,  102°,  100°,  103°,  101.8°; 
on  the  third  day,  103.6°,  103.4°;  on  the  fourth  day,  i03°-[-, 
106.6°;  on  the  fifth  day,  107°,  108.2°.  Pulse  till  end  of 
fourth  day,  82,  56,  90,  106;  respiration,  19,  34,  24,  40. 

Lesions. — Fracture  beginning  at  left  external  angular 
process  of  frontal  bone,  comminuting  orbital  plate,  extend- 
ing into  body  of  sphenoid,  and,  after  bifurcation,  terminat- 
ing in  cribriform  plate  and  in  squamous  portion  of 
right  temporal  bone ;  two  lacerations  of  inferior  surface  of 
left  frontal  lobe — one  near  its  centre  as  large  as  a  hickory 
nut,    containing  disintegrated  clot  and   brain  tissue,    the 


CASES    VERIFIED    BY   NECROPSY.  427 

other  smaller  and  more  superficial,  encroaching  upon 
middle  portion  of  Sylvian  fissure ;  two  other  slight 
lacerations  upon  inner  border  of  right  occipital  lobe ;  slight 
subarachnoid  serous  effusion  upon  upper  surface  of  cere- 
bellum ;  general  hyperasmia  with  some  minute  coagula. 

Case  LX.  Symptoms. — Consciousness  not  lost,  but 
delirium  continued  from  time  of  injury  till  final  coma; 
contusion  behind  left  ear;  very  slight  dilatation  of  pupils; 
delirium  became  violent.  At  the  end  of  two  or  three  hours 
the  patient  became  aphasic;  he  could  utter  single  words 
correctly,  or  a  number  of  words  in  succession,  each  correct 
in  itself,  but  strung  together  without  sense  or  logical  se- 
quence, as  "water  —  father — when,"  or  "Jesus  —  now — 
who."  He  also  connected  fragments  of  words  with  each 
other,  as  "en — is — other,"  meaning  when  is  mother;  or  "J 
— mother,"  for  Jesus,  mother;  or  "J — ter,"  for  Jesus, 
water;  sometimes  "ter — J,"  for  water,  Jesus.  The  clew 
to  these  fragmentary  words  and  sentences  was  found  in 
the  words  he  constantly  used  singly.  The  aberrations  of 
speech,  like  the  delirium,  continued  till  final  coma,  and 
were  constant.  On  the  second  day  his  head  was  extended, 
but  without  cervical  rigidit}';  he  was  restless  and  irritable; 
the  pupils  were  still  normal ;  urine  was  retained ;  coma 
and  stertor  supervened,  and  death  occurred  thirty-seven 
hours  and  a  half  after  admission.  The  temperature  on 
admission  was  100.2°,  rose  progressively  in  twenty  hours 
to  105.2°,  remained  stationary  for  twelve  hours,  and  again 
rose  progressively  to  108.6'.  One  hour  post  mortem  it  was 
110°.  The  pulse  constantly  increased  in  frequency  from 
90  to  190.  The  respiration  did  not  exceed  24  for  thirty- 
two  hours,  after  which  it  was  from  40  to  50. 

Lesions.  —  Fracture  extending  from  left  superior 
occipital  fossa,  through  posterior  condyloid  foramen, 
into  foramen  magnum;  epidural  hemorrhage,  slight 
over  occipital  lobes  and  more  abundant  in  inferior 
occipital  fossae;  cortical  hemorrhage  in  central  part  of  an- 
terior fossae  and  over  sella  turcica;    thrombi  in  left  lateral 


428  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

and  superior  petrosal  sinuses;  posterior  meningeal  veins, 
including  those  of  larger  size,  greatly  distended ;  some 
opacity  of  arachnoid  membrane  and  subarachnoid  serous 
effusion  over  right  occipital  lobe.  Lacerations  con- 
fined to  base,  except  in  case  of  left  temporo-sphenoidal 
lobe.  The  first  left  temporal  convolution  was  lacerated 
through  the  whole  thickness  of  its  cortex  for  a  length  of 
one  inch  and  a  half,  which  included  the  second  and  part  of 
its  third  fifths,  estimated  from  its  anterior  extremity,  and 
its  middle  portion  involved  the  second  convolution.  This 
laceration  was  limited  to  the  exact  width  of  the  two  convo- 
lutions and  was  covered  by  the  unruptured  arachnoid.  A 
small  and  deep  laceration  existed  upon  the  inferior  surface 
of  this  lobe,  and  another,  small  and  shallower,  was  situ- 
ated at  its  tip,  involving  all  three  of  its  convolutions.  A 
similar  slight  laceration  occurred  at  the  anterior  extremity 
of  the  right  temporo-sphenoidal  lobe,  including  the  second 
and  third  convolutions.  There  was  an  extensive  lacera- 
tion of  the  under  surface  of  the  left  frontal  lobe,  extend- 
ing from  its  anterior  border  to  the  optic  chiasm  and  from 
the  median  line  outward  through  the  first  and  second  into 
the  third  orbital  convolution ;  it  disintegrated  the  cortex 
and  the  subcortex  to  a  considerable  depth,  and  the  resul- 
tant hemorrhage  had  broken  through  into  the  arachnoid 
cavity.  There  was,  fi.nally,  a  small  contusion  about  the 
centre  of  the  inferior  surface  of  the  right  frontal  lobe. 
The  brain  substance  was  generally  hypersemic  with  minute 
thromboses,  and  a  small  amount  of  reddish  serum  occupied 
the  lateral  ventricles. 

Case  LXI.  Symptoms. — No  evidence  of  brain  lesion 
on  admission,  twenty-four  hours  after  injury,  except  right 
radial  pulsation  was  fuller  and  stronger  than  the  left ;  fol- 
lowed by  delirium,  with  delusions,  after  sixteen  hours, 
which,  with  the  unsymmetrical  pulse^  persisted  for  five 
days.  On  the  sixth  day,  mind  clear,  memory  restored, 
general  headache;  later,  delirium  at  intervals,  aimless 
inclination  to  get  out  of  bed,  increasing  difficulty  of  articu- 


CASES    VERIFIED    BY   NECROPSY.  429 

lation,  progressive  mental  impairment;  control  of  bladder 
and  rectum  lost.  On  the  twenty-fifth  day,  patient  quiet, 
weaker,  picking  at  the  bedclothes.  Twenty-sixth  and 
twenty-seventh  days,  delirium,  irritability,  great  sensitive- 
ness to  external  disturbances,  unconsciousness.  Death 
occurred  on  the  twenty-eighth  day.  Temperature  on  ad- 
mission, 102°;  second  and  third  days,  103°,  104.4°;  from 
this  time  it  was  usually  99°  to  99°+,  sometimes  normal, 
occasionally  loo^  until  the  last  eighteen  hours,  when  it 
suddenly  rose  to  105",  and,  with  slight  recessions,  finally 
reached  108°.  Pulse,  84  to  54,  till  the  last  four  days,  when 
it  exceeded  100 ;  but  in  the  last  twelve  hours,  with  the 
highest  temperature,  it  ranged  from  70  to  54.  Respira- 
tion was  accelerated  on  the  second  and  third  days,  but  at 
other  times  was  normal  till  within  a  few  hours  of  death. 
Right  axillary  temperature  the  day  before  death  was  from 
0.2°  to  1.2°  higher  than  the  left.  Temperature  one  hour 
post  mortem,  108°. 

Lesions. — An  open  fissure  extended  from  beneath  the 
torcular  Herophili,  downward  and  slightly  outward,  to  a 
point  near  the  left  m.argin  of  the  foramen  magnum,  where  it 
subdivided  to  enclose  a  quadrangular  depression  of  bone 
three-quarters  of  an  inch  by  half  an  inch  in  its  diameters ;  it 
was  then  continued  between  the  posterior  border  of  the 
petrous  portion  and  the  basilar  process  of  the  occipital 
bone,  where  it  terminated.  No  external  evidences  of  in- 
jury; small  epidural  hemorrhage  on  either  side  of  median 
line  at  commencement  of  fracture;  two  thin  laminar  spots 
of  epidural  clot,  each  about  half  an  inch  in  diameter,  firmly 
attached  to  dura  over  anterior  part  of  left  frontal  lobe, 
from  indirect  violence ;  corresponding  blood  stains  upon 
surface  of  bone,  but  under  surface  of  dura  not  discol- 
ored; large  subarachnoid  serous  effusion  over  vertex; 
meningeal  hyperaemia,  but  none  of  cerebral  surface. 
Four  lacerations  of  antero-superior  surface  of  left  pre- 
frontal lobe,  with  contusion  of  intermediate  cortex,  the 
whole  covering  a  space  one  inch  and  a  half  in  diam.eter ; 


430  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

another  laceration  of  small  size  a  short  distance  be- 
hind them;  small  laceration  upon  anterior  part  of  ex- 
ternal surface  of  right  frontal  lobe ;  these  lacerations 
all  extended  into  the  subcortical  substance  and  were 
partially  filled  with  necrotic  tissue ;  the  adjacent  brain 
substance  was  unaltered.  Marked  general  oedema  and 
hyperaemia,  with  moderate  number  of  punctate  extravasa- 
tions and  minute  thrombi;  brain  of  normal  consistence. 

Immediate  microscopic  examination  afforded  no  evi- 
dence of  inflammatory  action,  except  in  contiguity  to  the 
necrotic  tissue.  The  quadrangular  osseous  depression  was 
firmly  fixed,  but  there  was  no  osseous  deposit. 

Case  LXII.  Symptoms. — No  history;  walking  case; 
semiconsciousness,  but  without  speech  or  comprehension 
of  speech  then  or  afterward;  hemorrhage  from  left  ear, 
and  oedema  of  left  mastoid  region;  pupils  normal; 
early  delirium ;  sensitiveness  to  external  irritation  ;  reten- 
tion of  urine.  Second  day,  entire  unconsciousness;  con- 
vulsive movements  of  limbs;  Cheyne-Stokes  respira- 
tion ;  accumulation  of  mucus  in  trachea  and  bronchi, 
and  death  in  forty-two  hours.  Temperature  on  admission, 
101.6°;  in  twenty-four  hours,  103.2°;  in  twenty-seven 
hours  and  till  death,  108.6°;  one  hour  post  mortem,  108°. 
Pulse,  64  to  50;  second  day,  140  to  168.  Respiration,  nor- 
mal, 24,  16,  20. 

Lesions. — Haematoma  in  left  occipital  region ;  linear 
fracture  through  left  occipital  bone,  from  median  line 
and  along  groove  for  lateral  sinus,  across  petrous 
portion  by  a  wide  fissure,  and  separating  dorsum  ephip- 
pii  from  sphenoid  bone ;  thrombus  in  left  lateral 
sinus;  complete  disintegration  of  right  frontal  lobe  to 
within  half  an  inch  of  fissure  of  Sylvius  and  quite  to 
anterior  border  of  corpus  striatum;  deep  laceration 
of  greater  part  of  inferior  surface  of  left  temporo- 
sphenoidal  and  a  smaller  laceration  in  centre  of  in- 
ferior surface  of  right  temporo-sphenoidal  lobe ;  cor- 
tical hemorrhao^e  from  the  frontal  laceration  filled  all  the 


CASES   VERIFIED    BY    NECROPSY.  431 

basic  fossae  except  the  outer  part  of  the  left  anterior,  and 
one  clot  m  the  median  line  anteriorly  was  as  large  as  a 
mandarin  orange ;  it  also  covered  with  a  thin  coagtilum 
the  superior  and  lateral  surfaces  of  the  whole  right  and 
the  greater  part  of  the  left  hemispheres,  and  extended  over 
the  superior  surface  of  the  cerebellum ;  general  hyper- 
asmia,  with  a  few  minute  thrombi ;  minute  extavasations 
in  centre  of  pons,  the  largest  of  which  was  of  about  the 
size  of  a  robin  shot. 

Case  LXIII.  Symptoms. — Primary  unconsciousness, 
followed  by  mental  hebetude  and  mild  delirium,  which 
continued  till  death  ;  occasional  dysphagia  in  second  week, 
sometimes  extreme.  Temperature  on  admission,  99.2°, 
rose  in  two  hours  to  102°,  and  was  afterward  99°  to  100° 
and  loi'.  Pulse  on  admission,  50;  below  90  for  eight 
days;  afterward  exceeded  100.  Respiration  normal. 
Death  occurred  in  fourteen  days,  and  was  immediately 
preceded  by  extreme  dyspnoea  and  dysphagia. 

Lesions. — Fracture  through  left  occipital,  from  median 
line  to  petrous  portion  of  temporal  bone ;  extensive  lacera- 
tion of  antero-superior  and  inferior  surfaces  of  left  frontal 
lobe ;  cortical  hemorrhage  covered  with  a  thin  clot  the 
entire  left  hemisphere  and  the  posterior  half  of  the  right, 
and  filled  all  the  basic  fossae. 

Case  LXIV.  Symptoms. — Contusion  in  occipital  re- 
gion, and  recurrent  hemorrhage  from  left  ear;  violent 
delirium  after  thirty-six  hours ;  right  radial  pulse  fuller 
and  stronger  than  the  left  on  the  third  and  fourth  days. 
Temperature  on  admission,  98.4°,  rose  in  twelve  hours  to 
102°,  and  afterward  varied  from  98.5°  to  100°-]- in  the 
morning,  and  from  99.5^  to  100.8°  in  the  evening;  last 
observation,  six  hours  ante  mortem,  101.6°.  Pulse 
and  respiration  were  practically  normal.  Death  in  ten 
days. 

Lesions. — Fracture  through  posterior  part  of  left  parie- 
tal, into  petrous  portion  of  temporal  bone;  transverse  lac- 
eration across  inferior  surface  of  right  frontal  lobe  at  junc- 


432  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

tion  of  its  anterior  and  middle  thirds,  which  was  subcortical 
except  at  outer  extremity,  where  hemorrhage  had  broken 
through  the  surface;  small  laceration  of  anterior  fourth  of 
second  right  temporal  convolution,  mainly  subcortical; 
cortical  hemorrhage  in  right  middle  and  posterior  fossae, 
and  to  a  small  amount  in  right  anterior  fossa;  moderate 
general  hyperasmia,  with  a  few  minute  coagula. 

Case  LXV.  Symptoms. — Consciousness  lost  and  par- 
tially restored;  persistent  occipital  pain;  admission  to 
hospital  four  days  later;  stupor  merging  in  final  uncon- 
sciousness ;  loss  of  control  of  bladder  and  rectum ;  right 
radial  pulse  fuller  and  stronger  than  the  left,  but  difference 
not  strongly  marked;  pupils  normal.  Temperature  on  ad- 
mission ioo°;  normal,  with  exception  of  eight  hours  on 
the  seventh  day,  when  it  was  from  99.2''  to  99.4°,  till  ten 
hours  ante  mortem;  final  temperatures,  99.2°  to  103.8°; 
pulse,  45  to  80;  respiration,  14  to  18.     Death  in  ten  days. 

Lesions. — Hsematoma  in  left  occipital  region;  biparietal 
and  left  parieto-occipital  sutures  loosened  but  not  sepa- 
rated ;  small  laceration  on  under  surface  of  right  frontal 
lobe  anteriorly;  cortical  hemorrhage  covered  the  whole 
lateral  and  superior  surfaces  of  both  hemispheres,  except 
in  left  lower  parietal  region,  extended  into  median  fissure 
and  beneath  tentorium  over  superior  surface  of  cerebellum, 
and  occupied  both  anterior  and  both  middle  fossae.  The 
effusion  was  thin,  except  at  the  base  and  over  the  frontal 
lobes,  where  the  clot  was  thick,  firm,  black,  and  closely 
adherent  to  the  cortex,  and  could  be  traced  into  the  frontal 
laceration  from  which  it  originated.  A  still  smaller  lacer- 
ation existed  upon  the  inferior  surface  of  the  right  temporo- 
sphenoidal  lobe.  The  brain  was  moderately  hyperasmic  and 
very  oedematous  in  its  cerebral  portion.  There  were  no 
punctate  extravasations,  few  minute  thrombi,  and  no  in- 
flammatory products. 

Case  LXVI.  Symptoms. — Complete  unconsciousness, 
which  continued  till  death;  hemorrhage  from  nose  and 
mouth;    pupils    contracted  and  immovable,  but  in  a  few 


CASES   VERIFIED    BY   NECROPSY.  433 

hours  left  became  dilated;  some  convulsive  movements 
of  right  arm;  retention  of  urine;  second  day,  ecchy- 
mosis  of  both  eyes  and  subconjunctival  hemorrhage  in 
right;  continued  dilatation  of  left  pupil;  right  normal. 
Temperature  on  admission  101°;  in  four  hours,  102";  in 
sixteen  hours,  105°,  and  in  twenty-four  hours,  106°;  pulse 
and  respiration  frequent  throughout.  Death  in  twenty- 
six  hours. 

Lesions. — Extravasation  of  blood  into  substance  of 
left  temporal  muscle  disclosed  by  incision ;  open  fissure 
extended  from  squamous  portion  of  right  temporal  bone 
across  both  orbital  plates  and  intervening  cribriform  plate 
of  ethmoid,  broke  off  left  lesser  wing  of  sphenoid,  crossed 
left  middle  fossa  and  petrous  portion,  and  terminated  in 
left  margin  of  foramen  magnum ;  epidural  clot  occupied 
the  whole  right  anterior  fossa,  and  another  of  smaller 
size  the  left  middle  fossa ;  a  thrombus  filled  the  posterior 
part  of  the  superior  longitudinal  sinus ;  cortical  hemorrhage 
over  superior  surface  of  the  cerebellum,  derived  from  a 
small  laceration  of  its  lateral  border;  small  pial  hemor- 
rhages over  left  parietal  and  temporo-sphenoidal  lobes,  and 
a  larger  one  over  right  parietal  lobe ;  large  subcortical  lacer- 
ation of  left  temporo-sphenoidal  lobe,  excavating  its  sub- 
stance beneath  second  and  third  convolutions  and  anterior 
portion  of  the  first  convolution,  which  did  not  reach 
the  surface;  moderate  general  hyperaemia,  more  marked  in 
pons  and  cerebellum. 

Case  LXVII.  Symptoms. — Patient  walked  two  miles 
to  the  hospital  gate  and  was  carried  unconscious  to  the 
ward ;  ecchymosis  of  right  eye  and  wide  dilatation  of  right 
pupil ;  slight  contraction  of  the  left ;  no  motor  or  sensory 
disturbances;  left  brachial  pulsation  full  and  strong,  the 
right  very  small  and  weak ;  same  conditions  existed  in  the 
radial  arteries,  but  the  contrast  somewhat  obscured  by 
contusion  of  the  left  wrist.  Temperature  on  admission ,  98° ; 
four  hours  later,  104.6°;  immediately  after  death,  105°; 
one-half  hour  post  mortem,  105.4°;  pulse,  40  to  64;  respira- 
28 


434  INJURIES    OF    THE   BRAIN   AND    MEMBRANES. 

tion,  32  to  2,^;  cyanosis  just  before  death,  at  the  end  of 
five  hours. 

Lesions. — Contusion  of  scalp,  disclosed  by  incision,  ex- 
tending from  coronal  suture  backward  above  temporal 
ridge;  fracture  in  right  middle  fossa,  involving  both  squa- 
mous portion  of  temporal  and  greater  wing  of  sphenoid 
bone ;  firm  epidural  clot  from  laceration  of  anterior  branch 
of  arteria  meningea  media,  measuring  three  fluid  ounces, 
which  filled  right  middle  fossa  and  flattened  temporal 
lobe  laterally  and  inferiorly.  When  the  clot  was  re- 
moved the  brain  retained  its  position,  widely  separated 
from  the  base,  and  leaving  the  anterior  petrous  surface 
and  the  adjacent  middle  fossa  exposed.  The  smaller 
superficial  veins  and  arterioles  of  the  brain  were  congested, 
and  the  surface  between  them,  at  first  pale,  was  soon  uni- 
formly reddened.  There  was  a  small  laceration  of  the 
posterior  part  of  the  third  left  temporal  convolution ;  an- 
other, somewhat  smaller  than  a  buckshot,  was  found  in  the 
anterior  part  of  the  pons  at  the  apposition  of  the  trans- 
verse and  longitudinal  fibres.  The  brain  substance  was 
generally  hyperaemic,  especially  in  the  left  hemisphere, 
but  without  minute  extravasations  or  thrombi.  The  sur- 
faces of  section  soon  became  deeply  reddened  and  bathed 
in  watery  effusion. 

Case  LXYIII.  Symptovis.  —  Partial  unconciousness; 
recurrent  hemorrhage  from  right  ear,  succeeded  by  a  flow 
of  serous  fluid ;  vomiting;  dilatation  of  both  pupils ;  reten- 
tion of  urine ;  greater  fulness  and  strength  of  the  left  radial 
pulse  than  of  the  right;  mental  condition  normal;  inter- 
current bronchitis  on  the  third  day,  which  ran  its  usual 
course ;  from  the  second  day  a  peculiar  dusky  and  swollen 
appearance  of  the  face,  which  continued  till  within  two  or 
three  days  of  death ;  no  other  indications  of  cerebral  in- 
jury till  the  fourteenth  day,  when  there  was  occipital  pain, 
which  became  general  headache,  and  a  little  later  there  were 
somnolence  and  occasional  irritabilit3\  On  the  eighteenth 
day,  the  fifth  of  this  epoch,  posterior  cervical  rigidity ;  delir- 


CASES   VERIFIED    BY   NECROPSY.  435 

ium ;  temperature  at  its  maximum  ;  tenderness  along  the 
course  of  the  larger  nerves  of  the  left  lower  extremity 
from  the  twentieth  to  the  twenty-fifth  days;  delirium 
more  active,  lucid  intervals  less  frequent,  somnolence 
more  continuous,  and  sense  of  hearing  impaired ;  deafness 
progressive  till  complete ;  power  of  articulation  gradually 
lost,  and  finally  communication  possible  only  by  gesture ; 
dysphagia  occurred  more  suddenly  and  a  little  later.  The 
mental  condition  varied  from  normal  to  that  of  stupor  or 
delirium ;  emaciation  was  progressive ;  paralysis  and  hy- 
perassthesia  of  the  left  lower  extremity  were  of  late  occur- 
rence ;  recurrence  of  posterior  cervical  rigidity  was  once 
noted,  but  was  transitory;  toward  the  end,  control  of  urine 
and  faeces  was  lost ;  during  the  last  twelve  hours  uncon- 
sciousness was  complete,  and  respiration  rapid,  insufficient, 
and  entirely  nasal.  Death  occurred  on  the  thirty-first  day. 
The  temperature  on  admission  was  97°,  became  normal  in 
four  hours,  and  was  afterward  99°  till  the  invasion  of 
bronchitis,  on  the  third  day,  when  it  rose  to  103°,  and 
subsided  with  recovery  from  the  comi plication.  On  the 
tenth  day  it  again  rose  with  the  recurrence  of  intracranial 
symptoms  to  103.4°,  and  afterward  varied  from  100°  to 
104°,  and  was  not  often  less  than  101° +.  The  post- 
mortem temperature  receded  in  one-half  hour  from  103.4° 
to  103°.  The  axillary  temperatures,  carefully  recorded 
from  the  sixth  day,  were  symmetrical  in  nearly  half  the 
observations,  and  in  the  others  usually  varied  two-tenths 
of  a  degree,  and  were  rather  more  frequently  higher  on 
the  right  side.  The  pulse  was  usually  from  64  to  90. 
The  respiration,  always  frequent,  was  rarely  less  than  30 
in  the  minute  from  the  time  of  admission. 

Lesions. — No  external  injury ;  linear  fracture  extending 
from  squamous,  through  petrous  portion  of  right  temporal 
bone;  simple  thrombosis  of  lateral  sinuses  from  torcular 
Herophili  into  jugular  veins;  punctate  extravasations  in 
pia  mater;  large  occipital  veins  distended;  no  serous  effu- 
sion   at   vertex,  but  patches  of    false    membrane,   mainly 


436  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

upon  left  frontal  lobe,  and  upon  either  side  of  median 
fissure.  Several  ounces  of  turbid  serous  effusion  at 
base,  and  a  large  amount  in  lateral  ventricles;  fibri- 
nous exudation  covering  pons,  medulla,  and  inferior 
surface  of  cerebellum,  one  to  two  millimetres  in  thick- 
ness, and  in  Sylvian  fissures;  limited  contusion  of 
posterior  part  of  surface  of  right  temporo-sphenoidal 
lobe,  covering  a  space  one  inch  square,  which  was  of 
a  yellowish  color  and  studded  with  hard  miliary  hemor- 
rhages; fornix  much  softened,  and  brain  substance  gen- 
erally hyperaemic  and  oedematous. 

Immediate  microscopic  examination  showed  the  mem- 
branous effusion  to  be  crowded  with  small  round  cells 
which  extended  for  some  distance  in  diminishing  quantity 
into  the  substance  of  the  underlying  cerebellum.  Other 
portions  of  the  brain  tissue  were  unchanged.  The  Strep- 
tococcus pyogenes  was  developed  from  cultures  of  the  exuda- 
tion. 

Case  LXIX.  Syuiptoms. — Consciousness  lost,  but  re- 
stored at  time  of  admission ;  haematoma  over  right  frontal 
region ;  vomiting ;  severe  frontal  headache ;  face  flushed ; 
pupils  normal;  temperature,  95° ;  pulse,  90;  respiration, 
20.  One  hour  later,  wide  dilatation  of  right  pupil,  and 
right  cornea  more  sensitive  than  left;  sudden  uncon- 
sciousness, followed  by  rigidity  of  left  side,  and  con- 
vulsive movements  of  right.  At  the  end  of  an  hour 
and  a  half,  temperature,  97°;  pulse,  85;  and  Cheyne- 
Stokes  respiration.  Death  in  three  hours  from  time  of 
injury. 

Lesions. — Linear  fracture  in  squamous  portion  of  right 
temporal  bone,  continued  through  anterior  part  of  middle 
fossa  and  terminating  in  body  of  sphenoid  bone;  large 
epidural  hemorrhage  over  lateral  surface  of  right 
hemisphere  nearly  to  median  fissure ;  blood  partially 
coagulated  and  derived  from  posterior  division  of  ar- 
teria  meningea  media;  surface  of  right  temporal  and 
anterior    part    of     right    occipital    lobe    somewhat     flat- 


CASES   VERIFIED   BY   NECROPSY.  437 

tened;  slight  contusion  of  left  second  temporal  convolu- 
tion ;  brain  moderately  hyperaemic  and  oedematous. 

Case  LXX.  Symptoms. — Patient  admitted  to  the  hos- 
pital without  history,  wholly  unconscious  and  with  Cheyne- 
Stokes  respiration ;  scalp  wound  in  right  occipital  region ; 
pupils  equally  dilated ;  right  radial  pulsations  fuller  and 
more  compressible  than  the  left;  temperature,  97.6°.  In 
thirty  minutes  the  right  pupil  became  normal,  and  in  four 
hours  also  the  left  pupil,  and  the  temperature  rose  to 
98.4°;  the  respiration  was  16,  and  the  pulse,  previously 
130,  was  reduced  to  92;  unconsciousness  continued.  In 
eight  hours  the  temperature  was  102°,  the  pulse  128,  and 
the  respiration  40;  the  patient  could  articulate,  and  an- 
swered "  Yes"  to  all  questions.  In  eleven  hours,  temper- 
ature, 103.2°;  pulse,  140;  respiration,  42;  and  in  twelve 
hours  death  ensued.  Temperature,  thirty  minutes  post 
mortem,  104.6°. 

Lesions. — Linear  fracture  from  right  occipital  tuber,  to 
left  petrous  portion.  Epidural  hemorrhage  in  left  pos- 
terior fossae ;  cortical  hemorrhage  over  both  hemispheres ; 
slight  lacerations  of  inferior  surface  of  both  frontal  and 
both  temporal  lobes ;  brain  substance  markedly  hyperaemic. 

Case  LXXI.  Symptoms. — Coma;  stertor;  pulse  strong 
and  irregular;  respiration  slow;  slight  dilatation  of  both 
pupils,  which  were  insensitive;  slight  twitching  of  both 
arms;  extremities  cold;  no  external  evidence  of  injury; 
temperature,  94.2°  to  101.2°;  respiration,  24,  20,  14; 
pulse,  42  to  52.     Death  in  eleven  hours. 

Lesions. — Linear  fracture  extended  from  just  above  and 
behind  right  ear  into  posterior  inferior  fossa;  enormous 
epidural  hemorrhage,  derived  from  posterior  division  of 
middle  meningeal  artery,  which  compressed  right  hemi- 
sphere; slight  laceration  of  the  right  parietal  lobe,  pos- 
terior to  fissure  of  Rolando. 

Case  LXXII.  Symptojns.  —  Unconsciousness,  which 
continued  till  death ;  contusions  and  superficial  wounds  of 
left  side  of  face  and  temporal  region ;    dilatation  of  both 


438  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

pupils,  of  the  right  more  than  of  the  left;  hemorrhage 
from  mouth,  nose,  and  right  ear;  relaxed  muscles,  and 
imperceptible  pulse  at  wrist.  Death  occurred  five  minutes 
after  admission,  and  in  about  an  hour  after  reception  of 
injury. 

Lesions. — Hasmatoma  over  left  temporal,  both  parietal, 
and  right  occipital  regions,  from  rupture  of  intracra- 
nial vessels ;  calvarium  crushed  on  left  side  anteriorly,  and 
its  fragments  deeply  depressed  and  distorted;  zygoma 
and  both  orbital  plates  comminuted;  body  of  sphenoid 
bone  disintegrated,  and  base  of  skull  extensively  fissured; 
thin  pial  hemorrhage  covered  entire  brain,  possibly  aug- 
mented by  some  cortical  effusion  at  base ;  limited  contu- 
sions confined  to  cortex  about  right  parieto-frontal  junction 
and  along  right  side  of  median  fissure;  cortical  lacera- 
tions upon  inferior  surface  of  left  frontal  lobe  and  at  tip 
of  left  temporo-sphenoidal  lobe;  brain  substance  generally 
hyperaemic  and  oedematous,  with  a  few  punctate  extrava- 
sations. 

Case  LXXIII.  Symptoms. — Patient  was  found  in  the 
early  morning,  sitting  in  a  chair,  in  which  he  was  said  to 
have  passed  the  night.  He  would  not  reply  to  questions, 
from  seeming  lack  of  comprehension.  He  could  walk, 
though  he  had  little  control  over  his  limbs ;  his  face  was 
pale  and  showed  traces  of  vomiting.  On  admission,  there 
were  partial  consciousness,  right  hemiplegia,  and  hemi- 
anaesthesia;  dilatation  of  left  pupil  and  contraction  of  the 
right;  loss  of  control  of  urine  and  faeces;  profuse  serous 
discharge  from  both  ears,  and  slight  oedema  of  lungs. 
Two  hours  later  coma  was  complete  and  oedema  of  the 
lungs  had  increased.  Death  occurred  in  ten  hours.  Tem- 
perature on  admission,  99.2°;  in  two  hours,  101.2°;  in  four 
hours,  103°;  in  six  hours,  103.4°;  in  nine  hours,  103.8°; 
in  ten  hours,  when  m  articiilo  mortis,  104°;  thirty  minutes 
post  mortem,  106°.  The  right  axillary  temperature  was 
0.2°  higher  than  the  left  at  each  observation.  Pulse,  90 
to  108;  respiration,  36,  30,  38. 


CASES    VERIFIED    BY    NECROPSY.  439 

Lesions. — Slight  hsematoma  over  right  parietal  region 
disclosed  by  incision ;  fracture  extending  from  right  of 
occipital  tuber,  across  petrous  portion,  into  greater  Aving 
of  sphenoid;  opacity  of  arachnoid  in  right  frontal  and  an- 
terior parietal  regions;  small  cortical  hemorrhage  over 
frontal  lobes;  extensive  laceration  of  frontal,  temporal, 
and  inferior  portion  of  parietal  lobes  on  left  side ;  these 
parts  were  excavated  and  filled  with  a  dark  solid  clot, 
which  was  extruded  in  large  quantity  through  a  long  tear 
made  in  the  process  of  removal  of  the  brain  from  the 
cranial  cavity ;  slight  ante-mortem  cortical  rupture  through 
which  a  little  blood  had  escaped  into  the  middle  fossa  and 
ascended  upon  the  frontal  region,  and  another  into  the 
posterior  cornu  of  the  lateral  ventricle,  through  which  the 
choroid  plexus  was  infiltrated ;  small,  deep  laceration 
upon  the  anterior  border  of  the  left  cerebellum;  moderate 
general  hyperaemia  and  marked  oedema,  with  a  few  punc- 
tate extravasations;  thrombi  in  the  superior  longitudinal 
and  lateral  sinuses. 

Case  LXXIV.  Syuiptoms. — Patient  received  a  scalp 
wound  two  days  previously,  and  Avas  found  unconscious. 
On  admission  to  the  hospital,  mental  condition  dazed  but 
rational;  temperature,  100°;  pulse,  68;  respiration,  20. 
Temperature  rose  on  second  day  to  102°  and  receded  on 
the  third  to  98.8°,  with  normal  pulse  and  respiration.  On 
the  fourth  day  a  general  convulsion  occurred,  rather  sud- 
denly, and  was  followed  by  four  others  between  morning 
and  night.  Temperature  remained  from  99"  to  98'  — ,  and 
on  the  fifth  and  sixth  days  was  from  98.4''  to  97'  — .  On  the 
seventh  day  stupor  with  loss  of  faecal  and  urinary  control, 
and  on  the  eighth  day  coma.  Temperature,  97"  to  98.8^ 
in  the  morning,  and  101.2°  to  100.2°  in  the  evening.  Pulse,. 
66,  138,  66,  102.  Respiration,  18,  36,  21.  On  the  ninth 
day,  coma  continued  with  contracted  pupils  and  progres- 
sive anaemia.  Temperature,  100.6"  to  loi"';  pulse,  152  to 
146;  respiration,  48,  54.  Death  occurred  on  the  tenth  day. 
Temperature  then,  iqi°  ;  and  one  hour  post  mortem,  100.8°. 


440  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

Lesions. — Slight  separation  of  anterior  portion  of  bi- 
parietal  suture,  continued  as  an  open  fissure  through  me- 
dian line  to  centre  of  frontal  bone,  and  thence  as  a  fine 
closed  fissure  through  supra-orbital  ridge  into  left  orbital 
plate.  Slight  epidural  hemorrhage  beneath  the  biparie- 
tal  suture.  Large  pial  hemorrhage  over  left  hemisphere, 
with  thick  clot  in  posterior  parietal  region,  and  extend- 
ing over  right  frontal  lobe  into  anterior  and  middle  fossae; 
slight  cortical  contusion  upon  inferior  surface  of  right 
temporal  lobe.  Arachnoid  opacity  along  margin  of  su- 
perior median  fissure.  Brain  substance  hyperaemic  and 
oedematous. 

Case  LXXV.  Symptoms. — Fell  down  a  flight  of  stairs ; 
still  unconscious  on  admission;  wound  in  left  occipito- 
parietal region;  hemorrhage  from  left  ear;  right  pupil 
irresponsive  and  widely  dilated,  left  pupil  moderately 
dilated ;  muscular  system  relaxed  ;  temperature  on  admis- 
sion, 95°,  and  in  one  hour  normal;  rose  progressively  to 
104.2°;  right  axillary  temperature  uniformly  from  0.2°  to 
0.4°  higher  than  the  left  till  the  last  observation,  when 
the  difference  was  2°;  respiration,  22  to  24;  pulse  on  ad- 
mission, 72,  irregular  and  intermittent,  and  afterward  78 
to  86  till  immediately  before  death,  which  occurred  in 
eight  and  one-half  hours. 

Lesions. — Fracture,  which  extended  from  left  inferior 
occipital  curved  line  through  petrous  portion  into  sella 
turcica;  laceration,  two  inches  long  by  an  inch  wide,  of 
inferior  surface  of  left  temporo-sphenoidal  lobe ;  another, 
half  an  inch  in  diameter,  at  anterior  extremity  of  first  left 
temporal  convolution;  and  a  third  upon  inferior  surface 
of  riofht  frontal  lobe,  which  involved  its  anterior  half; 
cortical  hemorrhage  filled  right  anterior  and  both  middle 
fossae,  covered  right  hemisphere  laterally,  and  extended 
as  a  thick  clot  over  right  frontal  lobe  and  along  corpus 
callosum  quite  to  cerebellum ;  some  small  extravasations 
in  substance  of  pons;  general  hyperaemia  and  punctate 
extravasations  in  anterior  and  posterior  portions  of  brain. 


CASES   VERIFIED    BY   NECROPSY.  44 1 

Case  LXXVI.  Symptoms. — Coma;  stertor;  left  pupil 
dilated;  small  wound  and  larger  hasmatoma  in  left  parietal 
region ;  sensation  diminished  in  both  lower  extremities 
and  muscular  twitching  in  right;  vomiting;  pulse,  52. 
After  trephination  a  soft  epidural  clot  was  discovered  and 
a  considerable  loss  of  blood  ensued.  Using  as  a  guide  a 
fissure  which  extended  through  the  squamous  and  petrous 
portions  into  the  middle  fossa,  the  bone  was  chiselled  and 
the  posterior  division  of  the  middle  meningeal  artery, 
which  was  found  to  be  the  source  of  hemorrhage,  was 
clamped.  The  pulse  increased  in  frequency  from  72  to  104; 
the  pupils  became  normal,  but  consciousness  was  not 
restored,  and  death  occurred  a  few  hours  later. 

Lesions  as  above. 

Case  LXXVII.  Symptoms.  —  Unconsciousness  and 
death  immediately  after  admission. 

Lesions. — Skull  crushed  and  flattened  on  right  side; 
fragments  very  movable ;  comminuted  on  left  side ;  ex- 
tensive laceration  of  brain  posteriorly  in  left  hemisphere; 
only  small  superficial  wounds  of  scalp. 

Case  LXXVIII.  Symptoms. — Coma;  stertor;  hemor- 
rhage from  left  ear;  contusion  of  left  parietal  region; 
pupils  dilated;  pulse  full  and  slow;  temperature  on  admis- 
sion, 98°,  and  rising  progressively  to  103.6°  at  time  of  death 
in  four  hours;  no  decrease  for  one  hour  post  mortem; 
respiration,  18  to  26;  pulse  on  admission,  70,  rising  to 
90. 

Lesions. — Fissure  extended  from  left  parietal  eminence, 
through  squamous  and  petrous  portions  into  middle  fossa ; 
deep  laceration  of  inferior  surface  of  right  temporo-sphe- 
noidal  lobe  and  of  lateral  border  of  right  cerebellum ;  cor- 
tical hemorrhage  filled  right  middle  fossa ;  hyperaemia  of 
right  side  of  brain. 

Case  LXXIX.  Symptoms.  —  Consciousness  lost  and 
not  regained ;  coma  grew  more  profound ;  slight  oedema 
of  scalp  in  right  temporal  region ;  pupils  slightly  dilated ; 
great  restlessness  and  irritability ;  lack  of  urinary  control ; 


442  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

temperature  on  admission,  100.4°,  and  rising  to  108°,  with 
only  two  or  three  brief  fractional  recessions;  pulse,  94, 
58,  80;    respiration,  28  to  24.     Death  in  forty-three  hours. 

Lesions. — Haematoma  over  whole  right  side  of  head; 
linear  fracture  from  right  frontal  through  parietal  bone 
into  inferior  occipital  fossa;  large  epidural  clot  over  whole 
base  on  right  side,  extending  upward  over  lateral  surface 
of  brain ;  laceration  of  inferior  surface  of  both  temporo- 
sphenoidal  and  both  occipital  lobes;  laceration  of  inferior 
surface  of  both  frontal  lobes  in  their  anterior  portion, 
very  extensive  on  left  side;  cortical  hemorrhage  over 
posterior  border  of  cerebellum;  extensive  general  hyperae- 
mia  with  punctate  extravasations. 

Case  LXXX,  Symptoms. — Immediate  unconsciousness. 
On  admission  to  the  hospital  pupils  unequal,  left  dilated, 
right  contracted,  neither  sensitive  to  light;  urine  retained. 
Temperature,  102.8°;  pulse,  96;  respiration,  20;  eighteen 
hours  later,  temperature,  103°;  pulse,  80;  respiration 
24 ;  no  change  in  general  s3^mptoms.  Operation  done  and 
an  epidural  clot  of  five  ounces  removed  from  temporo-parie- 
tal  region,  and  clear  fluid  from  arachnoid  cavity.  Tem- 
perature rose  in  four  hours  to  104.8°,  pulse  to  145,  and  respi- 
ration to  32  ;  after  sponge  bath,  temperature,  102.4°;  pulse, 
120;  respiration,  32,  No  change  in  pupils  at  any  time  pre- 
vious to  death.  On  the  following  day  delirium,  continued 
retention  of  urine,  and  convulsive  movements  of  both  eyes. 
Temperature,  102.4°,  103°,  101.8°;  pulse,  145,  128;  respira- 
tion, 30  to  32.  On  the  third  day,  temperature,  103.6°, 
102.6°,  104.4°,  reduced  by  sponge  bath  to  102.4°;  pulse, 
148  to  140;  respiration,  36  to  28.  Urinary  control  lost. 
On  the  fourth  day  temperature  was  again  reduced  from 
104.4°  to  102° -f-  by  sponge  bath.  Patient  restless  and 
delirious  at  times,  and  complained  much  of  pain  in  his 
head.  The  pupils  were  responsive  to  light ;  clot  protruded 
from  cranial  opening.  The  temperature  subsequently  varied 
from  102.6°  to  100.2°  on  the  sixth  day,  when  it  rose  pro- 
gressively to  106°,  and  was  again  reduced  to  102.2°  by  the 


CASES   VERIFIED    BY    NECROPSY.  443 

sponge  batli.  Death  occurred  two  and  one-half  hours 
later,  or  five  days  and  fourteen  hours  from  time  of  ad- 
mission. Temperature  thirty  minutes  post  mortem,  105°. 
Delirium  increased  during  the  last  day. 

Lesions. — Haematoma  in  left  parietal  region.  Linear 
fracture  beginning  in  anterior  and  inferior  part  of  left 
frontal,  running  upward  to  middle  of  parietal,  and  then 
downward  to  anterior  border  of  petrous  bone  in  middle 
fossa.  A  second  fissure  extended  from  the  first,  at  the 
fronto-parietal  junction  to  the  sella  turcica,  crossing  the 
groove  for  the  anterior  branch  of  the  middle  meningeal 
artery.  Large  epidural  clots  compressed  the  left  hemi- 
sphere ;  one  weighed  three  and  one-half  ounces.  Lacera- 
tion, one-half  by  one-fourth  inch  in  diameters,  of  inferior 
surface  of  left  temporal  lobe  anteriorly,  and  one  still  smaller 
of  inferior  surface  of  left  frontal  lobe.  Cortical  hemorrhage 
over  left  fissure  of  Rolando.  Lateral  ventricles  distended 
with  serous  fluid  ;  also  third  ventricle ;  iter  e  tertio  ad  quar- 
tum  ventriculum  as  large  as  a  goose  quill ;  and  small  hemor- 
rhage in  floor  of  fourth  ventricle,  clot  one-eighth  inch  in  dia- 
meter at  base  of  calamus  scriptorius.  Moderate  general 
cerebral  hyperaemia. 

Case  LXXXI.  Symptoms.  —  Large  haematoma  over 
left  frontal  region ;  epistaxis  and  hasmatemesis ;  simple 
fissure  from  left  frontal  eminence  into  orbital  plate,  dis- 
closed by  incision.  On  the  sixth  day  muscular  twitch- 
ing of  whole  right  side,  including  extremities,  but  not 
the  face,  which  ceased  entirely  in  fourteen  hours  and  was 
followed  by  left  hemiplegia  and  hemiansesthesia.  On  the 
seventh  day  a  convulsion,  confined  for  thirty  minutes  to 
the  right  side  but  afterward  becoming  general,  occurred 
two  hours  before  death.  Temperature  on  admission  was 
100.2°,  rose  to  104.4°  on  the  same  day,  and  to  105.6°  on  the 
next,  with  recessions,  and  afterward  varied  from  102°  to 
105.2°,  with  no  observation  for  six  hours  ante  mortem. 
Pulse  on  admission  was  120,  and  subsequently  130  to  152. 
Respiration,  26  on  admission,  and  later  44  to  58. 


444  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

Lesions. — Fracture  extended  from  the  orbit  through 
posterior  part  of  ethmoid,  and  the  body  and  right  lesser 
wing  of  sphenoid  into  floor  of  right  middle  fossa:  gen- 
eral subarachnoid  purulent  effusion,  most  marked  in  left 
frontal  region  below  site  of  fracture. 

Case  LXXXII.  Symptoms. — Conscious  on  admission; 
Cheyne-Stokes  respiration  ;  dilatation  of  left  pupil ;  right 
radial  pulse  fuller  and  stronger  than  the  left ;  haematoma 
on  right  side  of  the  head  anterior  to  occipital  junction, 
and  small  lacerated  wounds  over  both  frontal  eminences; 
muscular  contractions  of  left  side,  and  later  of  both  sides 
of  body.  On  admission,  temperature,  99.3°;  pulse,  104; 
respiration,  19. 

Lesions. — Multiple  fracture;  fissure  across  frontal  bone 
above  orbits,  extending  on  either  side  through  parietal 
bone  to  median  line  of  vertex  on  both  sides,  thence  to 
occiput,  and  on  right  side  behind  ear  to  within  an  inch 
of  foramen  magnum ;  another  fissure  on  left  side  ex- 
tended through  orbital  plate  of  frontal  and  lesser  wing 
of  sphenoid  into  middle  fossa.  Dura  and  pia  mater  were 
lacerated  from  right  mastoid  region  to  a  point  just  beyond 
median  line.  Right  motor  area  extensively  lacerated, 
and  right  optic  thalamus  and  corpus  striatum  to  lesser 
extent.     Left  hemisphere  was  uninjured. 

Case  LXXXIII.  Symptoms. — Patient  came  home  in  a 
dazed  as  well  as  intoxicated  condition,  and  said  he  had 
been  assaulted  and  robbed.  He  was  afterward  weak  and 
his  mind  wandered ;  three  days  later  he  was  found  uncon- 
scious and  sent  to  the  hospital.  On  admission  he  was  un- 
conscious, muttered  incoherently  when  roused,  and  the 
right  eye  was  contused  and  the  pupil  contracted;  right 
arm  and  leg  slightly  rigid.  Death  occurred  in  fourteen 
hours.  Temperature  rose  progessively  from  104°  to  106°, 
pulse  from  108  to  204,  respiration  from  22  to  68. 

Lesions. — Haematoma  of  right  temporo-occipital  region; 
stellate  fracture  above  right  ear  with  fissures  running 
through  sella  turcica  into  left  middle  fossa;    trivial  epi- 


CASES    VERIFIED    BY    NECROPSY.  445 

dural  hemorrliage  from  diploic  vessels  at  point  of  fracture ; 
slight  pial  hemorrhage  upon  under  surface  of  right  frontal 
lobe;  limited  subarachnoid  sero-purulent  effusion  upon 
posterior  border  of  left  cerebellum  in  an  area  not  more 
than  one  inch  in  diameter.  Excessive  hypersemia  and 
moderate  oedema  of  brain. 

Case  LXXXIY.  Symptoms. — Patient  found  uncon- 
scious in  the  street.  On  admission  to  the  hospital,  pupils 
symmetrical  but  irresponsive  to  light.  Temperature,  98°; 
pulse,  100;  respiration,  30.  Death  occurred  suddenly  in 
one  hour.     Respiration  had  dropped  to  4  or  5  per  minute. 

Lesions. — ^Wound  in  median  line  of  occiput;  linear 
fracture  extending  from  a  point  just  to  right  of  occipital 
median  line,  forvard  and  upward  into  right  squamous 
portion  and  downward  through  both  occipital  fossae  nearly 
to  foramen  magnum ;  slight  epidural  hemorrhage  at  ver- 
tex along  line  of  fracture ;  cortical  hemorrhage  over  left 
temporal  and  parietal  lobes  laterally,  and  in  somewhat 
larger  amount  over  inferior  surface  of  left  frontal  lobe 
anteriorly ;  pial  hemorrhage  over  whole  left  side  of  base 
of  brain,  covering  pons  at  its  posterior  border,  and  form- 
ing a  large  clot  upon  posterior  surface  of  medulla ; 
superficial  lacerations  of  inferior  surface  of  left  frontal 
lobe,  one  situated  along  median  fissure  and  another  near 
external  border;  right  cerebellar  lobe  completely  exca- 
vated b}^  subcortical  laceration,  and  filled  with  clot;  both 
lateral  ventricles,  and  the  fourth  ventricle,  distended  with 
clot  and  serum  derived  from  contusion  of  choroid  plex- 
uses ;  brain  substance  moderately  hyperaemic  and  exces- 
sively oedematous. 

Some  subarachnoid  effusion  and  opacity  of  arachnoid 
membrane  over  posterior  parietal  and  anterior  occipital 
regions  probably  preceded  injury. 

Case  LXXXV.  Symptoms. — Primary  and  permanent 
unconsciousness ;  wound  above  right  superciliary  ridge ; 
ecchymosis  of  both  eyes;  stertor;  hemorrhage  from 
mouth,  nose,  and  both  ears;  left  pupil  dilated,  right  con- 


44^  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

traded,  and  both  insensitive ;  fibrillar  twitching  of  right 
chest  muscles.  No  paralysis  or  muscular  rigidity.  The 
temperature  on  admission  was  99.4°;  pulse,  120,  full 
and  strong;  respiration,  13;  the  temperature  rose  to  99.6°, 
and  the  respiration  was  reduced  to  4.  Death  occurred  in 
twenty  minutes ;  immediate  post-mortem  decline  in  tem- 
perature. 

Lesions. — An  extensive  comminuted  fracture  of  frontal 
bone  and  both  frontal  plates  extended  through  the  middle 
fossae  into  the  petrous  portions ;  the  left  optic  nerve  was 
crushed  by  a  fragment  of  bone  in  the  optic  foramen.  The 
inferior  surface  of  both  frontal  lobes  was  deeply  lacerated 
over  its  whole  extent,  and  a  cortical  hemorrhage,  still 
fluid,  occupied  all  the  basic  fossae,  and  covered  the  pons 
and  medulla. 

Case  LXXXVI.  Symptoms. — Primary  and  permanent 
complete  unconsciousness ;  hemorrhage  from  left  nostril ; 
dilatation  of  both  pupils ;  no  convulsions  or  muscular 
rigidity;  respiration  not  more  than  four  to  five  in  the 
minute  at  any  time  after  the  receipt  of  injury  and  finally 
not  more  than  one ;  pulse  continued  full,  strong,  and  of 
normal  frequency  for  some  moments  after  respiration 
ceased.     Death  in  forty-five  minutes. 

Lesions.  — Fracture  extending  through  left  side  of  base 
into  middle  fossa;  moderate  pial  hemorrhage  covering 
whole  surface  of  brain,  vertex,  and  base,  and  also  me- 
dulla ;  marked  general  hyperaemia  and  oedema ;  contusion 
of  under  surface  of  left  temporo-sphenoidal  and  frontal 
lobes. 

Case  LXXXVII.  Symptoms. — Primary  and  permanent 
unconsciousness ;  stertor ;  dilatation  of  pupils ;  loss  of 
urinary  and  faecal  control,  and  pulmonary  oedema;  left 
radial  pulsation  fuller  and  stronger  than  right;  no  ex- 
ternal injury.  Temperature,  104°  to  104.8°;  pulse,  120 
to  166;  respiration,  24  to  52.  Death  in  four  hours  and  a 
half. 

Lesions. — Fracture  extending  into  both  occipital  fossae, 


CASES   VERIFIED    BY   NECROPSY.  447 

and  a  fissure  from  indirect  violence  in  right  middle  fossa ; 
large  indirect  epidural  hemorrhage  over  right  frontal 
region;  complete  excavation  of  right  frontal  lobe  with 
rupture  of  inferior  cortex  and  consequent  cortical  hemor- 
rhage over  superior  surface  of  whole  right  hemisphere 
and  left  frontal  lobe;  contusion  of  third  left  temporo- 
sphenoidal  convolution  and  small  extravasation  into  cen- 
tre of  pons ;  general  hyperaemia. 

Case  LXXXVIII.  Syviptoms. — Patient  found  uncon- 
scious in  the  street.  Pupils  slightly  contracted,  urine 
retained ;  ecchymosis  in  left  mastoid  region,  which  in- 
creased. Temperature,  105°,  and  pulse  frequent.  Con- 
dition remained  unchanged  and  death  occurred  in 
fourteen  hours. 

Lesions. — Hasmatoma  covering  Avhole  occipital  region. 
Linear  fracture  extending  through  both  inferior  occipital 
fossae  into  petrous  portions  of  temporal  bones.  Thick 
epidural  clot  in  the  course  of  the  fracture.  Cortical  hem- 
orrhage ;  clot  over  both  frontal  lobes,  more  complete  on 
left  side,  and  extending  into  all  basic  fossae.  Laceration 
of  inferior  surface  of  left  frontal  lobe,  extending  subcorti- 
cally  into  anterior  cornu  of  left  lateral  ventricle,  also  cross- 
ing median  line  superficially  and  then  extending  subcorti- 
cally  backward  to  a  point  opposite  to  posterior  part  of  the 
right  corpus  striatum.  This  laceration  largely  excavated 
both  frontal  lobes.  A  small  laceration  existed  upon  the 
inferior  surface  of  the  left  temporal  lobe  anteriorly.  The 
brain  substance  was  generally  hypersmic,  with  many 
patches  in  which  the  vessels  were  filled  with  minute  co- 
agula. 

Case  LXXXIX.  Symptoms. — Patient  found  in  deep 
coma;  stertor;  left  pupil  slightly  dilated.  On  admission 
to  the  hospital  scalp  wound  in  right  parietal  region  with 
linear  fracture ;  hemorrhage  from  both  nostrils ;  and  both 
pupils  slightly  dilated  and  irresponsive.  Temperature, 
97.4°;  pulse,  96;  respiration,  20.  Coma  continued,  with 
Cheyne-Stokes  respiration.      Temperature,   99.8°;    pulse, 


44^  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

no;  respiration,  24.  Death  forty-five  minutes  later  and 
six  hours  after  admission. 

Lesions. — Linear  fracture  extended  from  middle  portion 
of  right  parietal  bone  through  groove  for  middle  menin- 
geal artery  into  middle  fossa.  Large  epidural  hemor- 
rhage greatly  compressed  right  hemisphere. 

Case  XC.  Symptoms. — Patient,  after  having  fallen 
into  the  hold  of  a  vessel,  walked  about  a  block  and  then 
fell,  but  though  stupid  was  able  to  rise  and  to  walk  a  little 
farther;  then  became  slightly  delirious.  On  admission  to 
the  hospital,  mental  condition  irritable  and  speech  inco- 
herent, right  pupil  dilated  and  irresponsive  to  light. 
Temperature,  98.4°;  pulse,  64;  respiration,  16.  Two 
hours  later  there  was  a  unilateral  convulsion,  beginning  in 
the  left  leg  and  extending  to  the  arm,  which  was  followed 
by  coma  continuing  till  death  four  hours  after  admission. 
In  the  interval  there  were  six  similar  convulsions.  Tem- 
perature at  time  of  first  convulsive  seizure,  99°;  pulse,  86; 
respiration,  20;  temperature  just  before  death,  99.2°; 
pulse,  122;  respiration,  22. 

Lesions. — Contusion  of  scalp  about  left  parieto-occipital 
junction;  linear  fracture  extending  from  this  point  to 
within  one-half  inch  of  foramen  magnum ;  superficial  lac- 
eration of  inferior  surface  of  left  occipital  lobe,  one  inch 
in  length  and  corresponding  cortical  clot  not  larger  than 
a  half-dollar;  very  moderate  cerebral  hyperasmia.  The 
previous  history  of  this  patient  was  unknown. 

Case  XCI.  Symptoms. — Patient  while  in  an  alcoholic 
condition  fell  a  distance  of  five  stories,  striking  upon  his 
head ;  primary  and  permanent  unconsciousness ;  severe 
hemorrhage  from  left  ear,  nose,  and  mouth,  which  con- 
tinued till  death  thirty  minutes  afterward. 

Lesions. — Ecchymosis  of  both  eyes  and  extensive  haema- 
toma  of  scalp ;  depressed  fracture  of  right  parietal  bone 
near  median  line  with  multiple  fissures  extending  to  base 
and  involving  middle  and  posterior  fossas  on  both  sides 
and   left   petrous    portion.     Two    fissures    completely    in- 


CASES   VERIFIED    BY    NECROPSY.  449 

eluded  the  calvariiim,  and  another  passed  through  the 
body  of  the  sphenoid  bone.  An  independent  fissure  from 
indirect  violence  ran  backward  from  the  foramen  mag- 
num. Small  epidural  hemorrhage  beneath  depression  at 
vertex;  pial  hemorrhage  from  meningeal  contusion  over 
right  hemisphere ;  superficial  laceration  of  inferior  surface 
of  left  temporal  lobe  with  a  small  consequent  cortical 
hemorrhage  in  middle  fossa ;  both  lateral  ventricles  blood 
stained,  and  the  left  communicating  with  a  small  lacera- 
tion in  occipital  lobe.  The  ventricular  hemorrhage  was 
apparently  from  contusion  of  the  choroid  plexuses.  The 
brain  substance  was  moderately  hyperaemic,  with  thrombi 
in  the  minute  vessels. 

Case  XCII.  Symptoms. — Patient  found  unconscious 
in  the  street,  but  delirious  when  admitted  to  the  hospital 
one  hour  later;  pupils  slightly  dilated,  and  afterward 
irregular;  urine,  at  first  voided  naturally,  was  afterward 
retained.  Temperature  on  admission,  98°;  rose  to  100.4°, 
and  on  the  third  day  to  103°,  and  receded  to  102.6°  before 
death,  at  the  end  of  three  and  one-half  da3's;  pulse,  100  to 
130;  respiration,  20  to  26. 

Lesions. — Linear  fracture  extending  from  right  occipital 
region  to  petrous  portion  on  either  side.  Laceration  of 
inferior  surface  of  left  temporal  lobe,  and  of  left  fron- 
tal lobe  near  inner  border.  Extensive  contusion  of  pos- 
terior border  of  left  occipital  lobe,  involving  cortex  and 
subcortex  to  a  depth  of  one  inch,  and  the  tissue  softened, 
grayish,  and  filled  with  dark  punctate  extravasations. 
Cortical  hemorrhage  over  left  hemisphere  at  both  base  and 
vertex. 

Case  XCIIL  Symptoms.  —  Patient  after  a  fall  of 
thirty-two  feet  found  unconscious  w4th  profuse  hemor- 
rhage from  the  right  ear;  on  admission  to  the  hospital, 
stupid ;  unable  to  give  any  account  of  his  accident  then  or 
afterward ;  profuse  hemorrhage  from  the  ear  continued ; 
deviation  of  eyes  to  the  right;  vomiting,  restlessness,  and 
general  muscular  twitchings  through  the  day;  no  other 
29 


450  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

symptoms  except  some  frontal  headache.  On  the  third 
day  the  hemorrhage  from  the  ear  was  replaced  by  a  pro- 
fuse serous  discharge  which  continued  till  death.  The 
mental  condition  was  dull,  but  rational,  with  frontal  head- 
ache and  occasional  restlessness;  no  disturbance  of  speech. 
On  the  fourth  day  slight  delirium,  which  was  afterward 
continuous  and  became  muttering,  and  was  later  active  in 
character.  On  the  fifth  day  there  were  dry  tongue  and 
picking  at  the  bedclothes,  and  on  the  sixth  day  the  skin 
was  clammy  and  there  were  large  bronchial  rales.  On 
the  seventh  day  the  pupils,  which  had  been  normal,  were 
very  slightly  dilated,  the  conjunctival  reflex  was  absent  in 
the  right  eye,  and  the  lids  did  not  respond  to  irritation ; 
the  left  lid  and  conjunctiva  were  very  sensitive.  Restless- 
ness continued  till  death.  The  temperature  on  admission 
was  98°,  rising  to  102.8°  on  the  second  day,  to  103.8°  on 
the  third,  to  104°  on  the  fourth,  to  105°  on  the  fifth, 
to  106°  on  the  sixth  and  seventh,  with  unimportant  re- 
cessions. The  pulse  did  not  exceed  108  in  frequency,  and 
the  respiration  was  from  20  to  28  till  death  on  the  sev- 
enth day. 

Lesions. — No  injury  of  the  scalp;  linear  fracture  begin- 
ning in  the  right  squamous  portion  of  the  temporal  bone 
at  a  point  just  above  the  petrous  portion,  to  Vv'hich  it  ex- 
tended in  two  fissures,  one  running  along  its  anterior  sur- 
face, and  the  other  crossing  its  superior  border  and  poste- 
rior surface  and  extending  to  foramen  magnum.  The 
posterior  petrous  surface  was  comminuted,  and  one  small 
fragment  was  quite  detached  and  clinging  to  the  dura. 
There  were  moderate  subarachnoid  serous  effusion  and 
arachnoid  opacity  in  the  right  parietal  region.  Purulent 
effusion  existed  in  moderate  amount  upon  the  anterior 
border  of  the  pons  and  upon  the  posterior  border  and  con- 
tiguous portion  of  the  inferior  surface  of  the  cerebellum. 
There  was  also  a  full  drachm  of  laudable  yellow  pus  in  the 
median  line  between  the  reflections  of  the  arachnoid  mem- 
brane  upon  the  cerebellar  lobes.     No  effusion  upon  the 


CASES   VERIFIED   BY   NECROPSY.  45 1 

medulla  or  cervical  portion  of  the  spinal  cord.  There  were 
a  slight  cortical  contusion  of  the  right  parietal  lobe  and  a 
large  cortical  contusion,  three  by  two  and  a  half  inches  in 
diameters,  involving  the  middle  portion  of  the  first  left 
temporal  convolution  and  the  contiguous  parietal  surface, 
marked  by  dark  discoloration  and  punctate  extravasations ; 
no  laceration.  The  brain  substance  was  excessively  hy- 
peraemic  and  oedematous,  but  without  thrombi.  The  right 
lateral  ventricle  was  filled  with  clear  serous  effusion,  and 
the  left  contained  a  lesser  amount. 

Case  XCIV.  Symptoms. — Patient  found  unconscious; 
pupils  slightly  contracted;  hemorrhage  from  the  nose. 
On  admission  to  the  hospital,  pupils  normal,  small  haema- 
toma  in  left  posterior  temporal  region,  and  a  cessation  of 
nasal  hemorrhage.  Eight  hours  later  pupils  dilated, 
muscular  twitchings  in  both  arms,  and  ecchymosis  of  left 
anterior  frontal  region.  .  Profound  unconsciousness  with- 
out change  in  symptoms  continued  till  death  fifteen  hours 
after  admission.  Temperature,  97.6°;  rose  progressively 
to  103°,  and  immediately  receded  post  mortem.  Pulse, 
70  to  100;  respiration,  24  to  27. 

Lesions. — Three  fissures  radiated  from  the  occipital 
tuberosity ;  one  extended  forward  above  the  right  petrous 
portion  into  the  middle  fossa,  another  to  the  right  side  of 
the  foramen  magnum,  and  a  third  ended  in  the  left  infe- 
rior occipital  fossa.  Cortical  hemorrhage,  in  moderate 
amount,  covered  the  inferior  surface  of  both  frontal  lobes, 
filled  both  Sylvian  fissures,  and  extended  backward  in  the 
central  region  of  the  brain  from  a  point  just  in  front  of  the 
optic  chiasm  across  the  crura  cerebri  to  the  anterior  border 
of  the  pons,  and  also  reached  the  lateral  surface  of  each 
temporal  lobe.  A  small  pial  hemorrhage  was  found  upon 
the  superior  surface  of  the  cerebellum,  and  in  the  median 
fissure.  Laceration  of  inferior  surface  of  left  frontal  lobe, 
upon  its  anterior  and  external  border,  and  excavating 
its  subcortical  substance  to  a  moderate  extent.  Subcorti- 
cal contusion  of  anterior  part  of  right  optic  thalamus,  with 


452  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

punctate  extravasations.  Subcortical  laceration  of  pons  in- 
volving its  transverse  fibres,  filled  with  clot,  one-half  inch 
in  diameter.  Very  moderate  hypersemia  of  the  brain 
with  no  oedema. 

Case  XCV.  Symptoms. — Patient  transferred  from  al- 
coholic ward  without  history ;  general  convulsions,  stupor, 
and  loss  of  urinary  control ;  right  radial  pulsations  weaker 
than  the  left;  subconjunctival  hemorrhage  in  both  eyes, 
right  pupil  dilated ;  both  pupils  irresponsive  to  light,  and 
both  eyes  protruding.  On  the  second  day  occasional  rest- 
lessness, picking  at  the  bedclothes;  other  conditions  un- 
changed. On  the  third  day  loss  of  fsecal  control,  want  of 
symmetry  in  radial  pulsations  less  noticeable  but  obvious, 
restlessness  and  efforts  to  get  out  of  bed ;  pupils  as  before. 
On  the  fourth  day  coma  and  death,  which  occurred  in  three 
days  and  six  hours.  Temperature,  99°  on  admission  to 
ward,  rising  progressively  with  slight  recessions  to  105.2°; 
pulse,  120  to  140;  respiration,  24  to  48. 

Lesions. — Slight  haematoma  in  left  temporal  muscle. 
Linear  fracture  extending  across  both  lesser  wings  of 
sphenoid  bone  into  middle  fossae.  Slight  epidural  hem- 
orrhage, about  one  and  one-half  drachms.  Cortical 
hemorrhage  over  right  temporal  and  parietal  lobes.  Lac- 
eration of  right  temporal  lobe,  one  by  one  and  a  half 
inches  in  diameter,  and  confined  to  cortex ;  beneath  it 
punctate  extravasations.  Brain  exceedingly  hypersemic 
and  oedematous.  Serous  fluid  to  amount  of  two  drachms 
in  each  lateral  ventricle.      Basic  arteries  atheromatous. 

Case  XCVL  Symptoms.  —  Patient  fell  eight  or  ten 
steps,  striking  upon  his  head.  On  immediate  admission  to 
the  hospital:  surface  cold  and  moist;  semi-consciousness; 
pain  in  the  head ;  hemorrhage  from  both  nostrils ;  respira- 
tion rapid  and  irregular,  becoming  deeper  and  slower  upon 
disturbance ;  pupils  moderately  dilated  and  irresponsive  to 
light,  and  facial  paralysis  with  ptosis,  which  was  ascertained 
to  have  existed  previous  to  the  injury.  Incision  through 
a  haematoma  on  the  right  side  of  the  head,  anterior  to  the 


CASES   VERIFIED    BY   NECROPSY.  453 

occipital  tuberosity,  disclosed  a  depressed  and  fissured 
fracture;  and  a  loose  fragment  of  bone,  two  inches  by 
one  inch  in  diameters,  was  removed.  Through  the  day 
the  pupils  were  symmetrically  contracted,  the  pulse  was 
intermittent,  respiration  irregular,  and  patient  very  rest- 
less and  irrational,  with  loss  of  urinary  control.  On  the 
second  day  restlessness  continued,  with  muscular  twitch- 
ings  in  both  upper  and  lower  extremities.  Death  occurred 
at  the  beginning  of  the  third  day  without  change  in  symp- 
toms. Temperature  on  admission,  97.2°,  rising  progres- 
sively through  the  day  to  105.2°.  In  the  morning  of 
the  second  day,  temperature,  102.6";  rose  progressively  to 
106.8",  and  with  one  recession  to  105.2°  again  rose  to 
106.8°  at  the  time  of  death,  with  an  immediate  post-mortem 
decline.  Pulse,  96,  148,  120,  180;  respiration,  26,  48, 
24,  44. 

Lesions. — Haematoma  over  right  side  of  head  and  occi- 
put; skull  crushed  and  flattened  with  radiating  fissures 
involving  base;  epidural  hemorrhage  over  left  occip- 
ital and  posterior  part  of  left  parietal  lobes ;  pial  hemor- 
rhage over  both  occipital  regions.  The  hemorrhages  were 
of  moderate  amount.  Laceration  of  inferior  surface  of 
both  frontal  lobes  anteriorly,  confined  to  cortex,  and  of 
left  temporal  lobe ;  slight  contusion  of  inner  border  of 
left  parietal  lobe;  slight  cortical  hemorrhage  at  base; 
brain  substance  throughout  very  hypersmic  and  oedema- 
tous. 

Case  XCA'^II.  Symptoms. — Loss  of  consciousness,  dila- 
tation of  left  pupil  and  contusion  of  left  palpebral  region, 
hemorrhage  from  both  nostrils,  and  clammy  skin.  Tem- 
perature, 98°;  pulse,  148;  and  respiration,  63.  Hemor- 
rhage from  left  nostril  continued  after  admission  to  the 
hospital,  and  temperature  rose  progressively  to  103.2°  at 
death  six  hours  afterward,  with  post-mortem  increase  to 
103.4°. 

Lesions. — Slight  contusion  of  scalp  in  left  parietal 
region ;  fracture  of  sphenoid  bone,  extending  from  crista 


454  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

galli  through  sella  turcica  into  its  left  lesser  wing;  lacera- 
tion of  inferior  surface  of  left  frontal  lobe,  two  and  one- 
half  inches  long  and  one-half  inch  in  depth;  slight  gen- 
eral hyperaemia  of  brain ;  no  hemorrhages. 

Case  XCVIII.  Symptoms. — Patient  thrown  from  a 
cable  car  and  struck  upon  the  back  of  his  head ;  conscious 
and  rational,  with  hemorrhage  from  left  ear  and  nose, 
Avhen  reached  by  ambulance  surgeon.  Pupils  and  muscu- 
lar action  normal,  and  radial  pulsations  symmetrical.  On 
admission  to  the  hospital  pain  in  left  occipital  region  and 
continued  hemorrhage  from  ear  with  haematemesis,  which 
was  frequently  repeated  during  the  day  and  night.  The 
pain  in  the  head  was  continued  till  stupor  supervened  (ten 
hours),  which  lapsed  into  coma  (fifteen  hours),  with  loss  of 
urinary  control,  slight  muscular  twitchings  upon  the  right 
side,  and  slight  dilatation  of  the  pupils.  Death  occurred 
in  twenty-seven  hours.  Temperature  on  admission,  98°; 
rose  progressively  to  104°,  with  a  single  recession  of  0.7°, 
and  one  hour  post  mortem  was  105°.  Pulse,  64  to  80; 
respiration,  20  to  38. 

Lesions. — Linear  fracture  extending  from  left  parieto- 
squamous  suture  anteriorly  to  eminence  for  semicircular 
canal  upon  anterior  surface  of  petrous  portion.  Slight  hem- 
orrhage into  substance  of  temporal  muscle,  but  none  upon 
surface  of  dura  mater.  Cortical  hemorrhage  over  whole 
superior  surface  of  left  hemisphere,  and  in  large  amount, 
in  both  posterior  and  both  middle  fossae.  Deep  laceration 
crossing  posterior  part  of  superior  surface  of  left  occipital 
lobe.  Entire  disintegration  of  whole  inferior  surface  of 
right  frontal,  and  of  anterior  half  of  left  frontal  lobe,  in- 
cluding cortex  and  subcortex,  to  a  depth  of  three-fourths 
of  an  inch.  On  the  right  side  the  laceration  reached  sub- 
cortically  quite  to  the  anterior  border  of  the  corpus  stria- 
tum, and  on  the  left  to  within  one-half  inch  of  the  same 
plane.  Hemorrhage  into  centre  of  pons  with  clot  one-half 
by  three-fourths  of  an  inch  in  diameters.  Moderate  gen- 
eral hyperaemia  and  oedema  of  brain. 


CASES   VERIFIED    BY   NECROPSY.  455 

Case  XCIX.  Symptoms.  —  Primary  and  permanent 
unconsciousness  after  a  fall  of  six  feet.  Right  pupil  di- 
lated, left  contracted,  both  irresponsive  to  light;  pulse  full 
and  slo\v,  and  radial  pulsations  symmetrical  at  the  wrists ; 
rigidity  of  entire  body,  which  continued  till  death  ;  hemor- 
rhage from  left  ear,  and  in  slight  amount  from  nose. 
Small  scalp  wound  in  left  occipital  region.  Later,  stertor, 
Cheyne-Stokes  respiration,  and  lack  of  urinary  control. 
Death  occurred  in  nine  hours.  Temperature  on  admis- 
sion, 98.4°;  in  three  hours,  103.2°;  in  six  hours,  106.2°, 
and  at  death,  109.2°;  thirty  minutes  post  mortem,  109.2°. 
Pulse,  60  to  108,  six  hours  after  admission;  respiration, 
34  to  37. 

Lesions. — Linear  fracture  extending  from  a  point  one 
inch  above  left  petrous  portion  of  temporal,  through  its 
anterior  surface  into  sphenoid  bone;  some  extravasation 
of  blood  into  temporal  muscle.  Cortical  hemorrhage,  in 
considerable  amount  and  partially  fluid,  covering  right 
hemisphere  superiorl)',  and  right  temporal  and  occipi- 
tal lobes  inferiorly,  derived  from  superficial  lacera- 
tion of  whole  lateral  surface  of  right  temporal  lobe. 
General  hypersemia  and  oedema  of  brain  not  very 
marked. 

Case  C.  Symptoms. — Primary  and  permanent  uncon- 
sciousness from  a  fall  of  fifteen  feet  upon  left  side  of 
head;  hasmatoma  over  left  fronto-parietal  region;  no 
hemorrhages;  stertor;  right  pupil  slightly  dilated ;  rigid- 
ity of  both  sides  of  body,  more  marked  upon  left.  On 
admission  to  the  hospital,  temperature,  101°;  pulse,  86; 
respiration,  20;  right  side  very  rigid  till  death  two  hours 
later.  Temperature  then  101°,  and  one-half  hour  post 
mortem,  102.1°. 

Lesions. — Linear  fracture  extending  from  frontal  emi- 
nence to  middle  of  left  petrous  portion.  Epidural  hemor- 
rhage over  an  area  of  three  inches  about  fronto-parietal 
junction ;  laceration  of  first  and  second  left  temporal  con- 
volutions, one  and  one-fourth  inches  long,  three-fourths  of 


456  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

an  inch  wide,  and  three-eighths  of  an  inch  deep ;  cortical 
hemorrhage  over  lateral  surface  of  lobe. 

Case  CI.  Syjnptoms. — Primary  unconsciousness  from 
a  fall  of  twenty  feet;  slight  wounds  of  face  and  a  fracture 
of  femur;  pupils  symmetrically  dilated;  hemorrhage  from 
left  nostril;  and  twitching  of  right  side.  After  admis- 
sion to  the  hospital,  patient  remained  in  a  semiconscious, 
restless  condition,  with  loss  of  urinary  control.  Second 
day,  same  conditions  continued,  with  dysphagia,  slight 
twitching  of  the  right  side,  great  weakness,  and  profuse 
perspiration,  till  death  at  the  end  of  thirty-seven  hours. 
Temperature  on  admission,  98°;  later,  102°+,  101°  +  for 
ten  hours,  and  then  progressive  rise  to  107.2°  with  imme- 
diate post-mortem  recession;  pulse,  104  to  160;  respira- 
tion, 24,  20,  60. 

Lesions. — Open  fissure  in  left  inferior  occipital  fossa 
running  into  groove  for  lateral  sinus ;  no  epidural  hemor- 
rhage ;  opacity  of  arachnoid  on  left  side ;  slight  cortical 
hemorrhage  over  left  temporal  lobe  posteriorly ;  lacera- 
tion of  inferior  surface  of  same  lobe,  one  inch  by  three- 
eighths  of  an  inch  in  size,  confined  to  cortex;  another 
laceration  of  the  same  dimensions  upon  inferior  surface 
of  left  occipital  lobe ;  marked  general  hypersemia  and 
oedema  of  brain  substance. 

Case  CII.  Symptouis. — Patient  admitted  to  the  hospi- 
tal after  having  fallen  to  the  ground  in  a  convulsion ; 
wound  in  right  parietal  region,  with  a  diffuse  hsematoma; 
no  hemorrhages ;  pupils  symmetrically  dilated ;  primary 
and  permanent  unconsciousness ;  no  muscular  symptoms ; 
several  convulsions  occurred  before  death  six  hours  later. 
Temperature,  100.6°  to  107°,  and  one  hour  post  mortem, 
108°;  pulse,  1 10;  respiration,  30. 

Lesions. — An  open  fissure  extended  from  squamous  su- 
ture into  petrous  portion ;  laceration  of  inferior  surface  of 
right  temporal  lobe,  one  inch  in  length ;  cortical  hemor- 
rhage over  fissure  of  Sylvius  and  island  of  Reil ;  pia  mater 
intensely    congested    with    subarachnoid    serous   effusion ; 


CASES    VERIFIED    BY    NECROPSY.  457 

h3'per^mia  and  oedema  of  the  brain  substance.  A  small 
gumma,  one-half  by  one-fourth  inch  in  size,  was  situated 
in  the  left  frontal  region. 

Case  CIII.  Symptoms.' — Patient,  aged  four  years,  fell 
one  story,  striking  his  head  upon  the  pavement.  Haema- 
toma  over  right  parietal  eminence  ;  hemorrhage  from  right 
ear;  primary  and  permanent  unconsciousness;  vomiting; 
no  muscular  symptoms,  except  loss  of  reflexes  on  the 
right  side.  On  admission  to  the  hospital,  temperature, 
97.6"^;  pulse,  144;  respiration,  28.  A  series  of  right  uni- 
lateral convulsions,  each  beginning  in  the  forehead  and 
involving  the  intercostal  muscles,  occurred  soon  afterward; 
each  paroxysm  was  violent  and  lasted  five  minutes,  fol- 
lowed by  repeated  attacks  of  vomiting,  and  by  paroxysms 
of  hiccough  which  alternated  with  stertor ;  loss  of  fsecal 
and  urinary  control.  The  right  leg  remained  in  tonic 
spasm.  Four  hours  after  admission,  temperature  was 
103.4°;  pulse,  120;  respiration,  40;  convulsions  upon  the 
right  side  had  ceased,  and  were  followed  by  constant 
twitchings  of  the  left  side  of  the  mouth  and  of  the  left  leg ; 
pulmonary  oedema  supervened,  and  death  occurred  at  the 
end  of  eighteen  hours.  The  temperature  fell  in  four 
hours  from  103.4°  to  100°,  and  then  rose  progressively  to 
109°,  with  immediate  post-mortem  recession.  The  pulse 
rose  from  no  to  150,  and  the  respiration  declined  from  40 
to  30. 

Lesions.- — ^Subperiosteal  haematoma;  simple  depressed 
fracture  involving  central  portion  of  right  squamous  su- 
ture, from  which  extended  two  fissures,  both  open  and 
filled  with  blood  clot — one  through  petrous  portion  to  fora- 
men ovale,  and  the  other  through  posterior  part  of  squa- 
mous portion  to  within  one-half  inch  of  parietal  angle; 
cortical  hemorrhage  in  middle  and  posterior  fossae  from  an 
extensive  direct  laceration  of  lateral  surface  of  temporal 
lobe  involving  both  dura  and  pia  mater. 

Case  CIV.  Symptoms. — The  patient's  head  was  struck 
in  the  occipital  region  by  a  descending  elevator  and  forced 


458  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

forward  upon  a  railing ;  scalp  wound  of  the  occiput  eight 
inches  long;  fracture  of  nasal  bones  and  contusion  of 
both  eyes ;  hemorrhage  from  both  nostrils ;  no  loss  of 
consciousness ;  no  muscular  symptoms  ;  pupils  slightly  di- 
lated, afterward  unchanged.  On  admission  to  the  hos- 
pital, vomiting  of  blood  and  partly  digested  food,  fol- 
lowed by  chill,  and  a  little  later  by  delirium ;  loss  of 
urinary  control,  which  was  permanent;  and  restlessness 
through  the  night.  Second  day,  patient  rational,  soon 
becoming  stupid,  restless,  and  at  night  suffering  severe 
pain  in  the  head  but  quiet  and  sleepless.  Third  day,  de- 
lirious, restless,  and  sleepless,  with  some  post-cervical 
rigidity,  and  twitching  of  fingers  of  both  hands.  There 
were  at  one  time  alternating  convulsive  movements  of  the 
lower  limbs,  flexion  of  one  at  the  knee  and  hip  being 
coincident  with  extension  of  the  other.  These  movements 
were  about  twenty  in  the  minute.  Death  occurred  at  the 
end  of  the  third  day.  The  temperature  on  admission  was 
ioo°,  rose  in  four  hours  to  104.4°,  fell  two  hours  later  to 
102.4°,  ranged  from  102°  to  102° -j-  till  end  of  second  day, 
and  afterward  from  104°  to  105.4°,  with  post-mortem  ele- 
vation to  105.6°.  The  pulse  varied  from  75  to  116,  and 
the  respiration  from  18  to  32. 

Lesions. — Fracture,  confined  to  anterior  fossae  and  ex- 
tending from  posterior  border  of  cribriform  plate  on  the 
right  side  by  a  wide  curve  forward  and  outward,  and  then 
inward  through  both  orbital  plates  to  a  corresponding 
point  on  the  left  side.  The  roof  of  the  orbits  was  elevated 
and  tilted  forward,  and  the  frontal  sinuses  were  made 
continuous  with  the  cranial  cavity.  Blood  clots  extended 
from  a  moderate  epidural  hemorrhage  upon  the  floor  of 
the  anterior  fossae  into  the  orbits.  Laceration  of  central 
portion  of  right  frontal  lobe,  one  and  one-half  inches 
by  three-eighths  of  an  inch,  confined  to  the  cortex,  and 
caused  by  a  ragged  projection  in  the  displaced  orbital 
fragment.  The  membranes  upon  the  posterior  half  of 
the  vertex    on    either  side   were  excessively  hyperaemic, 


CASES   VERIFIED    BY   NECROPSY.  459 

while  upon  the  anterior  half  they  were  of  a  dirty  yel- 
low color,  oedematous,  and  elevated  by  a  sero-purulent 
subarachnoid  exudation;  the  subjacent  convolutions  were 
flattened,  and  their  sulci  obliterated.  The  line  of  demar- 
cation was  well  defined.  In  the  posterior  segment  was  a 
pial  hemorrhage.  The  whole  base  of  the  brain  was  cov- 
ered with  a  purulent  effusion.  The  brain  substance  was 
excessively  hyperasmic  and  oedematous. 

Case  CV.  Symptoms. — Primary  and  permanent  un- 
consciousness ;  manner  of  injury  unknown ;  wound  in 
right  occipito-parietal  region,  right  pupil  dilated,  transient 
left  hemiplegia.  Temperature,  100°;  pulse,  90;  respira- 
tion slightly  increased  in  frequency  and  stertorous.  Ec- 
chymosis  over  right  mastoid  process  after  three  days. 
Right  unilateral  convulsions  began  on  the  fifth  day,  and 
continued  with  increasing  severity  and  frequency  till  death 
on  the  ninth  day.     Final  temperature,  103°. 

Lesions. — Fracture  of  right  occipital  bone,  extending 
from  point  of  external  injury  into  foramen  magnum  ;  no 
epidural  hemorrhage ;  laceration  of  right  parietal  lobe  at 
vertex  with  consequent  cortical  hemorrhage. 

Case  CVI.  Symptoms. — Patient  was  knocked  down 
and  struck  the  back  of  his  head  upon  the  sidewalk.  On 
admission  to  the  hospital  thirty  minutes  later,  contusion 
of  scalp  above  and  to  the  left  of  the  occipital  tuber,  stupor 
from  which  patient  could  be  roused  to  answer  simple  ques- 
tions, nearly  normal  pupils,  and  no  hemorrhages  or  mus- 
cular symptoms ;  profound  coma,  with  pupils  contracted  to 
a  pin's  point  and  entirely  irresponsive,  at  the  end  of 
twenty-four  hours.  In  thirty-five  hours,  slight  general 
convulsion ;  pupils  became  widely  dilated ;  pulse  rose  from 
60  to  160,  temperature  unchanged;  thirty  minutes  later 
respiration  suddenly  dropped  to  four  in  the  minute,  and 
death  occurred  thirty-five  minutes  afterward.  Tempera- 
ture on  admission  was  98°,  and  did  not  at  any  time  exceed 
102.4°;  pulse,  60  to  80,  till  second  day;  respiration,  i8 
to  28. 


460  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

Lesions. — Linear  fracture  extended  from  site  of  exter- 
nal injury  through  right  parietal  and  temporal  bones  to 
floor  of  middle  fossa ;  also  small  independent  fracture  in 
right  orbital  plate ;  epidural  hemorrhage  on  the  right  side 
extending  to  the  base ;  pial  hypersemia  with  minute  hem- 
orrhages over  same  area ;  laceration  of  right  temporal  lobe 
one  and  three-fourths  inches  long,  by  one  inch  wide,  and 
three-fourths  of  an  inch  deep,  and  filled  with  clot,  involv- 
ing posterior  part  of  first  and  second  convolutions;  super- 
ficial laceration  of  outer  half  of  inferior  surface  of  right 
frontal  lobe ;  laceration  in  centre  of  right  optic  thalamus, 
of  the  size  of  a  hazelnut,  with  punctate  extravasations 
near  its  margin ;  several  minute  hemorrhages  in  floor  of 
fourth  ventricle ;  cortical  hemorrhage,  covering  right  pa- 
rietal region  and  base,  extended  over  medulla.  General 
hyperasmia  of  brain  substance. 

Case  CVII.  Symptoms.  —  Patient,  aged  three  years, 
fell  forty  feet,  striking  the  right  side  of  his  head  upon 
the  pavement ;  primary  and  permanent  unconsciousness ; 
hsematoma  over  whole  lateral  parieto-occipital  region ; 
subconjunctival  hemorrhage  in  right  eye ;  pupils  normal ; 
left  radial  pulse  stronger  than  the  right;  several  convul- 
sions while  in  the  ambulance.  On  admission  to  the  hospi- 
tal the  convulsions  continued,  being  confined  to  the  right 
side,  and  involving  pectoralis  major,  deltoid,  and  supra- 
spinatus  and  infraspinatus  muscles  of  the  shoulder,  and  the 
adductors  of  the  hip  and  extensors,  causing  rotatory  move- 
ments of  the  arm  and  pounding  of  the  heel  at  every 
contraction ;  each  paroxysm  began  in  the  arm.  Loss  of 
urinary  control,  and  Cheyne-Stokes  respiration  for  two 
hours  before  death,  which  occurred  in  twenty-four  hours. 
Temperature  on  admission,  97.6°;  rose  to  105.2°,  with  im- 
mediate post-mortem  recession ;  pulse,  102  to  150;  respira- 
tion, 64,  44,  60. 

Lesions. — Compound,  comminuted,  depressed  fracture 
of  right  parietal  bone,  with  fissures  radiating  to  coronal 
and  lambdoid  sutures,  and  separation  of  sagittal  and  lamb- 


CASES   VERIFIED    BY   NECROPSY.  46 1 

doid  sutures;  a  fissure  extending  into  middle  fossa;  rup- 
ture of  dura  mater ;  epidural  hemorrhage  over  right  ver- 
tex; laceration  of  parietal  and  temporal  lobes,  three 
inches  by  one-half  inch  in  extent,  filled  with  clot,  and 
crossing  fissure  of  Rolando;  moderate  cerebral  hyper- 
semia,  most  marked  in  the  left  hemisphere. 

Case  CVIII.  Symptoms.  —  Patient  fell  from  a  mail 
wagon  to  the  ground,  striking  upon  his  head;  primary 
and  permanent  unconsciousness;  wound  and  hsematoma 
in  right  occipito-parietal  region ;  hemorrhage  from  right 
ear  and  nostril;  right  pupil  dilated,  left  contracted;  radial 
pulsations  symmetrical;  muscular  twitching  of  both  arms 
and  to  a  slight  extent  in  left  leg.  Temperature,  99°; 
pulse,  68;  respiration,  15.  No  change  in  symptoms. 
Death  in  forty  minutes.  Temperature,  98.4°,  with  imme- 
diate post-mortem  recession. 

Lesions. — Linear  fracture  extending  from  right  occip- 
ital bone  through  petrous  portion;  epidural  hemorrhage 
covering  right  hemisphere  and  forming  a  thick  clot ;  no 
lacerations ;  contusion  of  inferior  surface  of  right  temporal 
lobe.  General  cerebral  hyperaemia  and  cedema;  some 
fluid  in  lateral  ventricles. 

Case  CIX.  Symptoms.  —  Patient  fell  from  his  chair, 
and  was  said  to  have  been  in  a  convulsion ;  primary  and 
permanent  unconsciousness  ;  profuse  hemorrhage  from  the 
right  ear;  right  pupil  markedly  contracted,  the  left  di- 
lated; rigidity  of  left  arm  followed  by  twitching  of  the 
muscles.  On  admission  to  the  hospital,  temperature, 
97.2°;  pulse,  60;  respiration,  22;  four  general  convul- 
sions occurred  at  considerable  intervals,  in  the  last  of 
which  the  patient  died,  twelve  hours  after  admission. 
Both  pupils  had  become  equally  dilated.  Temperature 
rose  to  106.8°,  with  immediate  post-mortem  recession. 
Pulse,  60  to  96;  respiration,  22  to  40. 

Lesions. — No  external  injury,  except  small  effusion  of 
blood  over  right  mastoid  process.  Linear  fracture  ex- 
tended from  occipital  tuber  through  junction   of  middle 


462  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

and  anterior  thirds  of  the  right  petrous  portion  into  mid- 
dle fossa;  an  independent  fracture,  linear  in  the  outer 
table,  extended  from  the  anterior  inferior  angle  of  the  left 
parietal  bone  to  a  point  in  the  squamous  portion  opposite 
the  petrous  junction ;  a  small  triangular  bit  of  the  inner 
table  was  raised  upward  and  by  its  sharp  point  lacerated 
the  m.iddle  meningeal  artery  at  its  bifurcation ;  a  conse- 
quent epidural  hemorrhage  compressed  the  left  hemi- 
sphere laterally,  and  filled  all  the  basic  fossas  upon  that 
side ;  no  pial  hemorrhage ;  small  cortical  hemorrhage, 
derived  from  a  small  and  deep  laceration  of  the  external 
border  of  the  right  frontal  lobe,  covered  both  frontal  and 
the  left  parietal  lobes;  contusion,  one  inch  square,  of  left 
occipital  lobe  about  the  angular  gyrus ;  contusion  of  whole 
inferior  surface  of  left  temporal  lobe,  and  another  of  the 
anterior  two-thirds  of  the  inferior  surface  of  left  frontal 
lobe;  punctate  extravasations  in  the  pons ;  moderate  gen- 
eral hyperaemia  and  oedema. 

Case  CX.  Symptoms. — Patient  during  a  street  alter- 
cation was  jabbed  in  the  right  eye  with  the  end  of  an  um- 
brella; in  an  alcoholic  condition  when  admitted  to  the 
hospital  on  the  following  day.  Cornea  opaque  and  pupil 
immovable,  subconjunctival  hemorrhage,  and  constant 
pain  in  the  eye.  Temperature,  98.6°;  pulse,  80;  respira- 
tion, 20.  He  became  delirious  on  the  third  day,  and  from 
that  time  some  grade  of  delirium,  with  restlessness  and 
occasional  pain  in  the  head,  persisted  till  his  death  on  the 
forty-fifth  day.  On  the  forty-second  day  he  became  stupid, 
and  there  was  a  discharge  of  pus  from  the  orbit,  followed 
by  final  coma  and  loss  of  urinary  control.  There  were  at 
no  time  localizing  symptoms.  The  eye  was  removed  by 
Dr.  Callan  on  the  eighteenth  day.  The  temperature  on 
the  third  day  was  100°  to  102°;  on  the  fourth  day  101°  to 
104°;  and  till  the  forty-first  day  was  usually  from  98°-|- 
to  102°,  and  once  on  the  twenty-second  day  again  rose  to 
104°.  From  the  forty-first  to  the  forty-fifth  day  it  was 
from    104°  to    107.2°,   and  was  without   immediate   post- 


CASES   VERIFIED    BY   NECROPSY.  463 

mortem  change.  The  pulse  usually  ranged  from  68  to 
100,  and  the  respiration  Avas  only  moderately  increased  in 
frequency,  till  near  the  end  of  life. 

Lesiojis. — Only  a  fine  fissure  of  orbital  wall;  purulent 
subarachnoid  effusion  at  base,  most  marked  on  left  side 
and  upon  cerebellum,  and  extending  over  whole  lateral 
aspect  of  left  hemisphere ;  a  moderate  amount  of  muddy- 
looking  fluid  in  right  lateral  Yentricle  and  a  somewhat 
smaller  amount  in  left;  left  choroid  plexus  infiltrated  with 
pus  and  lymph.  Xo  other  lesions.  Simple  general  hy- 
peraemia. 

Case  CXI.  Symptouis.  —  Patient  struck  upon  the  head 
by  a  piece  of  chalk,  weighing  twenty  pounds,  which  had 
fallen  twenty  feet;  loss  of  consciousness  for  five  minutes. 
Hsematoma  in  left  supra-orbital  region,  extending  into 
the  eyelid ;  profuse  hemorrhage  from  left  ear  and  from 
both  nostrils;  free  haematemesis ;  right  radial  pulsa- 
tions stronger  than  left ;  pupils  normal.  On  admission  to 
the  hospital,  temperature,  98";  pulse,  68;  respiration,  24; 
parietal  fracture  disclosed  b}'  incision ;  restlessness  and 
irritability  after  restoration  to  consciousness.  Second 
day,  restlessness  and  twitching  of  the  right  arm  alter- 
nating with  somnolence;  the  left  radial  pulsations  had 
become  fuller  than  the  right,  and  this  condition  was  after- 
ward unchanged.  Third  to  fifth  days,  profuse  serous  dis- 
charge from  the  left  ear;  severe  pain  in  the  left  side  of  the 
head;  delirium  and  struggling  to  get  out  of  bed  at  night; 
delusions ;  loss  of  consciousness ;  and  finally  progressive 
asthenia,  irregular  and  labored  respiration,  dilatation  of  the 
left  pupil  and  contraction  of  the  right.  Death  in  four 
days  and  fourteen  hours.  The  temperature  did  not  exceed 
100°  till  within  the  last  twenty-four  hours,  when  it  rose  to 
106.6°,  and  receded  to  104.4°,  v'ith  immediate  further  post- 
mortem recession.  The  pulse  did  not  exceed  84  till  a  few 
hours  before  death;  respiration,  24  to  42. 

Lesions. — Linear  and  open  fissures,  which  were  con- 
fined to  left  side,  of  which  two  were  parallel  and  extended 


464  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

from  orbital  plate  through  vertex ;  coronal  suture  opened ; 
three  other  fissures  intersected  these  at  right  angles.  An 
independent  fracture  (indirect)  extended  from  left  fora- 
men ovale  to  tympanic  cavity.  Laceration,  one  and  one- 
half  inches  by  three-fourths  of  an  inch  in  extent,  filled  with 
clot,  upon  inferior  surface  of  left  frontal  lobe,  due  to  angu- 
lar elevation  of  orbital  plate ;  contiguous  subjacent  brain 
substance  yellow  and  slightly  indurated ;  adjacent  cortex 
the  seat  of  punctate  extravasations,  and  of  small  hemor- 
rhages; slight  epidural  hemorrhage  over  left  frontal  lobe; 
cortical  hemorrhage  at  base  of  brain,  about  four  ounces 
of  a  brownish-red  fluid ;  purulent  subarachnoid  effusion  at 
base  and  extending  into  spinal  canal ;  convolutions  at  base 
flattened,  cedematous,  and  yellow  in  color;  lateral  ventri- 
cles filled  with  a  sanious  fluid. 

Case  CXII.  Symptoms. — Patient  fell  down  one  flight 
of  stairs.  On  admission  to  the  hospital  hemorrhage  from 
mouth,  nOvSe,  and  left  ear,  and  subconjunctival  in  both 
eyes ;  partial  loss  of  consciousness,  which  became  complete ; 
temperature,  99.6°  to  103°;  pulse,  78;  respiration,  20; 
became  stertorous.     Death  occurred  in  seventeen  hours. 

Lesions. — Fracture  involving  both  orbital  plates  of 
frontal,  left  greater  wing  of  sphenoid,  left  petrous  por- 
tion, and  basilar  process  of  occipital  bone;  skull  thin  and 
brittle;  patient,  aged  fifty-five  years;  laceration  of  in- 
ferior surface  of  cerebellar  lobes. 

Case  CXIII.  Symptoms. — Patient  found  unconscious 
in  the  street.  On  admission  to  the  hospital,  profound 
coma ;  large  haematoma  in  right  occipito-parietal  region ; 
no  hemorrhages;  no  muscular  disorders,  but  marked  re- 
laxation; retention  of  urine  and  loss  of  faecal  control; 
pupils  symmetrical  and  moderately  dilated ;  temperature 
97.6°,  with  progressive  increase  to  107°  at  time  of  death 
fifteen  hours  after  admission,  and  no  immediate  post- 
mortem change;  pulse,  49  to  160;  respiration,  38  to  60. 

Lesions. — Fracture  extending  from  right  of  occipital 
tuber  into  occipito-temporal  suture ;  laceration,  one  and  one- 


CASES    VERIFIED    BY    NECROPSY.  465 

half  by  two  and  one-half  inches  in  extent,  of  inferior  surface 
of  right  occipital  lobe,  filled  with  clot  and  debris  of  brain 
tissue;  contusion  of  both  frontal  lobes. 

Case  CXIV.  Symptoms.  —  Patient  fell  twelve  feet, 
striking  upon  the  left  side  of  his  head ;  three  scalp 
wounds;  hemorrhage  from  left  ear;  primary  and  perma- 
nent unconsciousness ;  slight  dilatation  of  right  and  slight 
contraction  of  left  pupil.  Death  in  four  minutes  after 
admission  to  the  hospital. 

Lesions. — Compound  stellate  fracture  of  left  squamous 
portion  and  contiguous  occipital  bone,  with  open  fissures 
running  through  middle  and  posterior  fossse,  and  left 
petrous  portion ;  epidural  hemorrhage  in  left  occipital 
region,  about  two  ounces;  pial  hemorrhage  over  both 
hemispheres  and  cerebellum  ;  blood  coagulated ;  no  lacer- 
ation ;  independent  pial  hemorrhage  over  superior  cere- 
bellar surface;  clot  in  right  lateral  ventricle ;  not  much 
general  hyperaemia  and  no  oedema. 

Case  CXV.  Symptoms. — Patient  fell  in  the  street 
while  intoxicated  ;  rather  profuse  hemorrhage  from  left 
ear;  no  loss  of  consciousness;  pain  in  the  head;  stupor; 
in  the  opinion  of  the  family  mental  condition  different 
from  that  usual  to  the  patient  when  drunk ;  restlessness, 
headache,  and  stiffness  of  the  neck;  and  after  two  days 
admission  to  the  hospital.  There  was  then  no  external 
injury  of  the  head,  but  there  were  stupor,  somnolence, 
and  a  disposition  to  resist  every  disturbance ;  a  few  hours 
later  mechanical  restraint  became  necessary  and  delirium 
was  accompanied  by  delusions;  hemorrhage  from  left  ear 
recurred;  temperature,  which  on  admission  was  99.2°,  rose 
to  102°;  pulse,  50;  respiration,  30.  The  hemorrhage  from 
the  ear  and  the  delirium  continued  through  the  next  day, 
and  temperature  rose  progressively  to  105°,  and  was  then 
reduced  by  an  alcohol  bath.  The  hemorrhage  from  the 
ear  ceased,  delirium  diminished,  and  the  temperature  did 
not  exceed  103°-]-,  on  the  following  day.  Stupor  after- 
ward alternated  with  delirium,  the  temperature  of  five 
30 


466  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

days  ranged  from  102°  to  i02°-|-,  and  the  pulse  from  60 
to  112;  coma  supervened  and  death  resulted  from  asthenia 
on  the  ninth  day.  The  final  temperature  was  103.6°,  with 
post-mortem  increase  to  106.8°. 

Lesions. — Separation  of  lambdoid  suture  for  about  one 
inch,  and  linear  fracture  extending  from  it  through  left 
posterior  fossa  and  petrous  portion ;  laceration  of  inferior 
surfaces  of  both  frontal  and  both  temporal  lobes ;  exten- 
sive and  deep  in  the  left  frontal  and  left  temporal  lobe ; 
large  cortical  hemorrhage  in  all  the  basic  fossae,  espe- 
cially in  the  left  anterior  and  middle ;  moderate  subarach- 
noid purulent  effusion,  stained  with  blood,  mainly  at  the 
base.     General  cerebral  hyperaemia. 

Case  CXVI.  Symptovis. — Patient  fell  down  stairs  two 
days  previous  to  admission  to  the  hospital ;  ecchymosis  of 
right  eye ;  stupor  and  restlessness ;  retention  of  urine ; 
right  pupil  dilated  and  only  partially  responsive  to  light ; 
plantar,  patellar,  and  cremasteric  reflexes  absent.  Second 
day,  stupor  increased  progressively,  right  radial  pulsations 
stronger  than  the  left,  loss  of  urinary  control,  respiration 
irregular;  and  before  death,  which  occurred  in  forty-seven 
hours,  the  pupils  became  more  nearly  symmetrical,  the 
eyes  were  turned  to  the  right,  the  head  was  somewhat- 
extended,  and  there  was  commencing  pulmonary  oedema. 
The  temperature  was  in  the  first  twxnty-four  hours,  103°, 
100°,  104°;  and  in  the  second,  104.2°  to  107.2°,  with  no 
immediate  post-mortem  change.  The  pulse  was  100  to 
138,  and  the  respiration,  18  to  60. 

Lesions. — Linear  fracture  extending  from  anterior  part 
of  right  temporal  ridge  through  middle  fossa  into  horizon- 
tal plate  of  ethmoid  bone ;  small  epidural  clot  in  middle 
fossa,  and  a  corresponding  pial  hemorrhage  of  not  much 
larger  size ;  moderately  large  subarachnoid  serous  effu- 
sion ;  general  cerebral  hyperaemia  and  oedema ;  no  lacera- 
tion or  evidence  of  arachnitis. 

Case  CXVII.  Syviptouis.  —  The  patient  in  a  collision 
was   throwm   from   his  bicycle,  and  was  primarily  uncon- 


CASES    VERIFIED    BY    NECROPSY.  467 

scious.  He  was  taken  to  his  house,  where  he  had  a  con- 
vulsion, and  was  then  removed  to  a  hospital,  where  he 
remained  forty  days;  no  record  of  his  condition  during 
this  time  is  obtainable.  He  was  afterward  treated  by  an 
oculist  for  exophthalmos ;  he  resumed  his  professional  oc- 
cupation, and  was  said  to  have  been  in  good  physical 
health,  but  a  distinct  mental  change  was  observed  by  his 
family.  His  temper  was  irritable  and  his  conversation, 
which  had  been  hitherto  irreproachable,  became  remark- 
ably obscene  without  any  apparent  appreciation  on  his  part 
of  its  impropriety.  One  week  before  his  admission  to  St. 
Vincent's  Hospital,  and  six  months  after  the  reception  of 
the  injury,  he  became  suddenly  apathetic,  and  soon  fell 
into  a  stupor,  with  loss  of  faecal  and  urinary  control  and 
the  accession  of  a  febrile  movement.  When  admitted  to 
the  hospital  he  gave  no  response  to  questions  and  lay 
motionless  without  indication  of  intelligence  ;  a  faint  cica- 
trix was  visible  across  the  forehead;  the  odor  of  the  breath 
was  peculiar ;  the  left  pupil  was  much  dilated  and  entirely 
irresponsive,  and  the  right  eye  protruded ;  there  were  no 
muscular  symptoms,  and  the  radial  pulsations  were  sym- 
metrical. The  temperature  was  102°;  pulse,  120;  res- 
piration, 20.  Second  day,  low  delirium,  incoherence, 
and  at  times  deep  flushing  of  the  face.  Third  day,  gen- 
eral condition  unchanged.  Fourth  day,  more  restless 
and  actively  delirious ;  enema  given  and  boAvels  moved 
for  the  first  time.  An  examination  of  the  eyes  showed  a 
descending  neuritis  of  right  optic  nerve ;  and  an  exoph- 
thalmos of  the  right  eye,  increase  of  tension,  and  oedema 
of  the  retinoid  area,  probably  the  result  of  venous  obstruc- 
tion in  the  optic  foramen  (Gallon).  Nourishment  and 
medication  were  at  all  times  difficult.  Fifth  day,  restless- 
ness and  delirium  increased ;  the  pulse  grew  weaker  and 
the  respiration  more  frequent;  the  face  became  dusky, 
and  death  occurred.  The  temperature  was  increased  on 
the  third  day  from  ioi°-|-  to  i03°-io5°,  on  the  fourth 
day  reached  106°,  and  on  the  fifth  day  was  held  at  101.8° 


468  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

to  103.8°  by  alcohol  baths;  final  temperature  105.4°.  The 
pulse  ranged  from  130  to  146,  and  respiration  from  24  to  42. 

Lesions. — The  line  of  a  consolidated  fracture  extended 
from  the  left  temporal  fossa  across  the  forehead,  three- 
fourths  of  an  inch  above  the  supra-orbital  ridges,  to  a 
point  three- fourths  of  an  inch  internal  to  the  right  exter- 
nal angular  process,  and  then  with  a  curve  passed  upward 
and  inward  to  the  median  point  of  the  coronal  suture. 
The  line  of  former  fracture  was  very  faint  and  showed  no 
displacement  of  the  fragments;  on  the  inner  surface  of 
the  bone  it  was  rather  more  distinct ;  no  evidence  of  fis- 
sures leading  to  the  base.  The  inner  half  of  the  left  orbi- 
tal process  of  the  frontal  and  the  left  lesser  wing  of  the 
sphenoid  had  disappeared ;  the  free  edge  of  bone  was 
rounded,  and  the  remainder  of  the  process  was  white  and 
of  natural  appearance.  The  horizontal  plate  of  the  eth- 
moid, and  superior  surface  of  the  sphenoid  body,  had  also 
disappeared  from  the  crista  galli  to  the  dorsum  ephippii ; 
the  exposed  cellular  spaces  below  were  blackened  and  in- 
filtrated with  pus.  A  cyst  projecting  from  the  right 
frontal  lobe  with  the  investing  cerebral  membranes  rested 
in  this  central  cavity  of  bone.  Both  frontal  lobes  were 
much  softened,  yellowish  in  color,  and  adherent  to  the 
dura  mater.  The  anterior  inferior  portion  of  these  lobes 
was  too  much  softened  for  examination ;  their  superior 
surfaces  were  of  normal  character.  The  cyst  contained 
from  three  to  four  ounces  of  greenish-yellow  pus,  which 
was  subsequently  found  to  contain  the  Staphylococcus  py- 
ogenes aureus ;  it  was  confined  to  the  right  lobe  but  pro- 
jected across  the  median  line.  There  was  no  evidence  of 
former  hemorrhages  and  no  general  hyperaemia ;  but  there 
was  much  subarachnoid  fluid  beneath  the  cerebellum,  and 
the  brain  substance  was  very  oedematous. 

Case  CXVIII.  Symptoms. — Patient  fell  eight  feet  and 
was  found  unconscious ;  he  was  transferred  to  Bellevue 
from  another  hospital  ten  days  later,  and  was  then  in  vio- 
lent delirium.     Traces  of  hemorrhage  from  the  left  ear 


CASES   VERIFIED    BY   NECROPSY.  469 

and  of  a  wound  of  the  left  side  of  the  head  were  still  visi- 
ble ;  the  mouth  was  drawn  to  the  right,  the  reflexes  were 
generally  absent,  the  pupils  were  widely  dilated  and  in- 
sensitive, and  the  radial  pulsations  were  symmetrical.  He 
died  thirty-three  hours  afterward.  The  temperature  on 
admission  was  104.2°,  fell  to  102.8°,  and  at  death  was  107°, 
with  immediate  post-mortem  recession;  pulse,  no,  84,  150; 
respiration,  34,  30,  46. 

Lesions. — Three  fissures  originated  in  the  left  squamous 
portion,  one  of  which  was  open  and  traversed  the  whole 
length  of  the  anterior  surface  of  the  petrous  portion,  divid- 
ing in  the  middle  portion  into  two  branches,  one  terminat- 
ing in  the  sphenoidal  fissure,  and  the  other  in  the  pos- 
terior fossa ;  skull  thin  ;  epidural  clot  in  temporal  region  ; 
moderate  pial  hemorrhage  over  lateral  aspect  and  base  of 
left  temporal  region ;  laceration  of  second  right  temporal 
convolution ;  small  cloudy  subarachnoid  serous  effusion ; 
general  hypersemia  of  the  brain  substance  with  minute 
thrombi,  and  excessive  oedema,  which  involved  the  pons, 
medulla,  and  basal  ganglia;  two  or  three  punctate  extrav- 
asations in  the  centrum  ovale. 

Case  CXIX.  Symptoms.  —  Patient  fell  six  stories 
through  an  elevator  shaft ;  extreme  shock.  Primary  and 
permanent  unconsciousness ;  hemorrhage  from  right  nos- 
tril and  mouth ;  large  haematoma  in  right  frontal  region ; 
pupils  contracted,  the  left  more  completely  than  the  right. 
Temperature  on  admission  to  the  hospital,  97.2°,  and  rose 
progressively  to  102.2°  with  immediate  post-mortem  in- 
crease to  102.5°.  Death  occurred  soon  after  examination 
and  dressing  of  the  wounds. 

Lesions. — Wound  of  elbow-joint  and  compound  fracture 
of  leg;  open  fissure  of  right  frontal,  extending  through 
orbital  process  into  bod}'  of  sphenoid  bone ;  no  epidural 
hemorrhage ;  no  laceration ;  general  pial  hyperaemia  and 
oedema,  and  pial  hemorrhage  posteriorly ;  limited  contu- 
sion, in  an  area  of  one  and  one-half  inches  in  diameter, 
of  right  frontal  lobe  laterally. 


4/0  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

Case  CXX.  Symptouis. — Patient  fell  thirty-five  feet 
to  the  ground;  extreme  shock.  Transient  unconscious- 
ness ;  pupils  contracted ;  respiration  frequent,  and  became 
stertorous  and  flagging  in  the  ambulance.  On  admission 
to  the  hospital  consciousness  again  lost ;  large  hsematoma 
in  each  parieto-occipital  region ;  no  hemorrhages ;  right 
facial  paralysis;  right  forearm  strongly  flexed,  rigid,  and 
fingers  twitching;  left  forearm  slightly  rigid  and  flexed; 
within  the  first  hour  convulsive  movements  ever}'  ten 
minutes,  in  which  the  left  arm  was  drawn  in  toward  the 
chest,  and  both  legs  were  rigid  and  extended;  patellar 
reflexes  increased ;  right  pupil  dilated,  and  the  left  con- 
contracted;  face  cyanotic;  respiration  became  of  the 
Cheyne-Stokes  character;  stertor  and  moist  bronchial 
rales.  Temperature,  96.4°,  rising  progressively  to  100°  at 
time  of  death  twelve  hours  after  admission;  pulse,  62,  60; 
respiration,  32,  20,  28  ;  one  large  unconscious  urinary  evac- 
uation. 

Zrj-z'<?;/^\— Linear  fracture  ran  from  posterior  part  of 
right  parietal  bone  downward  and  forward  through  petrous 
portion  to  groove  for  middle  meningeal  artery ;  a  sec- 
ond linear  fracture  extended  from  the  middle  of  supe- 
rior curved  line  of  the  occipital  bone  through  posterior 
fossa  to  jugular  foramen ;  epidural  hemorrhage  from  rup- 
ture of  posterior  branch  of  right  middle  meningeal  artery ; 
three  ounces  of  fluid  blood  and  a  clot  one  inch  in  thick- 
ness at  point  of  rupture ;  laceration  of  right  temporal  lobe, 
small ;  cortical  hemorrhage  upon  lateral  aspect  of  parietal 
and  temporal  lobes;  general  contusion  confined  to  right 
lobe. 

Case  CXXI.  Symptoms . — Patient  found  unconscious 
beside  his  truck.  On  admission  to  the  hospital,  thirty 
minutes  later,  pulse,  80,  respiration  irregular,  and  tem- 
perature, 97.4°;  right  pulse  fuller  than  left;  no  hemor- 
rhages ;  no  muscular  symptoms ;  large  haematoma  just 
above  left  ear;  left  pupil  widely  dilated,  right  moder- 
ately contracted,   and  both  insensible  to  light.     Incision 


CASES   VERIFIED   BY   NECROPSY.  471 

disclosed  depressed  fracture  of  left  squamous  portion, 
with  free  hemorrhage  from  open  fissures.  At  the  end 
of  thirty  minutes  the  right  pupil  began  to  dilate  and  left 
facial  paralysis  was  appreciable ;  fifteen  minutes  later 
there  were  abduction  and  internal  rotation  of  both  thighs 
with  extension  of  the  legs,  and  in  ten  minutes  more  there 
was  flexion  of  forearms  with  adduction  of  the  arms.  The 
right  pupil  became  fully  dilated,  the  breathing  very  irreg- 
ular, and  death  occurred  one  and  one-half  hours  after  ad- 
mission. The  final  temperature  was  98.6°,  and  thirty 
minutes  post  mortem  had  risen  to  109°.  This  observation 
was  carefully  verified  by  Dr.  M.  W.  O' Gorman,  House 
Surgeon. 

Lesions. — Multiple  linear  fracture  of  left  squamous  por- 
tion ;  one  fissure  ran  forward  through  floor  of  middle  fossa 
to  border  of  sphenoid  body,  rupturing  anterior  branch 
of  left  middle  meningeal  artery ;  epidural  clot  compressed 
lateral  surface  of  left  temporal  and  parietal  lobes,  mak- 
ing them  concave,  and  also  inferior  temporal  surface. 
The  clot,  which  was  one  and  one-fourth  inches  in  thick- 
ness and  very  firm,  extended  nearly  to  the  median  line 
at  the  vertex  and  upon  the  lateral  surface  of  the  occip- 
ital lobe ;  no  other  hemorrhage,  and  no  laceration  or  lim- 
ited contusion  of  the  brain ;  pial  vessels  moderately  in- 
jected, and  no  subarachnoid  effusion  or  pial  oedema.  All 
parts  of  the  brain  were  moderately  and  equably  hy- 
peraemic,  without  punctate  extravasations  or  minute 
thrombi.  The  whole  brain,  inclusive  of  the  cerebel- 
lum and  basal  ganglia,  was  excessively  oedematous;  the 
ventricles  were  dry  when  first  exposed,  but  became  in 
part  filled  with  serum  by  exudation  from  the  cut  cerebral 
surfaces. 

Case  CXXII,  Symptoms. — Patient  fell  three  stories ; 
primary  and  permanent  unconsciousness;  hasmatoma  in 
left  parietal  region  and  at  vertex ;  hemorrhage  from  left 
ear  and  nose ;  right  radial  pulsations  fuller  and  stronger 
than  left;    right  pupil   dilated;    no  muscular  symptoms; 


4/2  IN'JURIES    OF    THE    BRAIN    AND    MEMBRANES. 

skin  cold  and  moist.  Temperature,  98.2°;  pulse,  68;  res- 
piration, 14.      Death  in  one  and  one-half  hours. 

Lesions.- — Separation  of  coronal  suture  through  its 
whole  length,  with  fissure  in  continuity  running  through 
right  orbital  plate,  body  of  sphenoid  bone,  and  floor  of 
middle  fossa,  and  separating  the  last  from  petrous  por- 
tion, which  was  also  involved;  multiple  fissures  of  right 
greater  wing  of  sphenoid ;  small  epidural  hemorrhage 
on  right  side ;  pial  hemorrhage  over  whole  of  right  and 
anterior  half  of  left  hemisphere ;  multiple  limited  con- 
tusions of  superior  surface  of  both  frontal  lobes,  and  of 
left  occipital  lobe ;  laceration  of  whole  inferior  surface  of 
right  temporal  lobe ;  small  laceration  of  inferior  surface 
of  right  frontal  lobe.  Brain  excessively  h3'peraemic,  with 
numerous  punctate  extravasations. 

Case  CXXIII.  Symptoms. — Patient  struck  by  a  falling 
wall ;  both  nasal  and  superior  maxillary  bones  fractured ; 
hemorrhage  from  mouth  and  both  nostrils ;  face  emphy- 
sematous; semiconsciousness;  left  pupil  slightly  dilated 
and  irresponsive  to  light;  no  muscular  symptoms,  no  loss 
of  fsecal  or  urinary  control,  and  radial  pulsations  symmetri- 
cal. Temperature,  100.6°,  rose  progressively  to  105.4°^ 
with  post-mortem  elevation  to  105.6°;  pulse,  100,  74,  138; 
respiration,  20  to  34. 

Lesions. — Cribriform  plate  and  crista  galli  detached  from 
the  ethmoid  body  and  pushed  upward  by  the  violent  dis- 
placement of  the  nasal  bones,  lacerating  the  anterior  per- 
forated space  in  the  median  line  to  a  depth  of  three- 
eighths  of  an  inch ;  small  cortical  hemorrhage ;  no  other 
laceration  or  hemorrhage;  general  hypersemia,  without 
much  oedema,  of  the  brain  substance. 

Case  CXXIV.  Symptoms. — Primary  and  permanent 
unconsciousness ;  hemorrhage  from  right  ear,  and  profuse 
from  mouth ;  ha;matemesis ;  right  pupil  dilated  but  re- 
sponsive to  light ;  left  radial  pulsations  stronger  than  the 
right;  no  muscular  .symptoms.  Temperature,  96.8°;  pulse, 
94;  respiration,  40. 


CASES   VERIFIED    BY   NECROPSY.  473 

Lesions. — Separation  of  coronal  suture  and  an  open  fis- 
sure in  continuation,  crossing  the  groove  for  the  right 
middle  meningeal  artery  and  the  middle  of  the  petrous 
portion  into  the  posterior  fossa;  large  epidural  hemor- 
rhage, flattening  the  right  hemisphere,  from  rupture  of 
the  trunk  of  that  vessel ;  slight  pial  hemorrhage  on  the 
right  side  posteriorly;  excessive  hypersemia  and  oedema 
of  all  parts  of  the  brain. 

Case  CXXV.  Symptoins.—VdXxQnX.  struck  upon  the 
head  with  a  piece  of  board ;  conscious  and  walking  about 
when  first  seen  by  the  ambulance  surgeon ;  condition  alco- 
holic. Wound  in  the  left  temporal  region  then  sutured, 
and  consciousness  suddenly  lost  immediately  afterward 
and  not  regained  ;  both  pupils  contracted  ;  general  muscu- 
lar twitching.  On  admission  to  the  hospital,  complete 
coma;  stertor;  temperature,  97°;  pulse,  50;  respiration, 
8,  and  subsequently  of  the  Cheyne-Stokes  character;  left 
pupil  dilated,  and  at  a  later  period  contracted.  Two  hours 
later  twitching  of  the  muscles  recurred  in  the  right  arm, 
and  was  followed  by  general  paralysis,  including  that  of 
both  sides  of  the  face  with  divergent  strabismus ;  urine 
ret  ined.  Death  in  eleven  hours.  Temperature  three 
hours  after  admission,  99.8°;  pulse,  54;  respiration,  22; 
seven  hours  after  admission,  temperature,  101°;  pulse,  56; 
respiration,  26;  in  ten  hours,  temperature,  102°;  pulse, 
58;  respiration,  26;  and  in  eleven  hours,  temperature, 
104°;  pulse,  68;  respiration,  22.  Temperature  thirty 
minutes  post  mortem,  106°. 

Lesions. — Fine  fissure  beginning  at  a  point  one-half 
inch  in  front  of  the  middle  portion  of  the  left  half  of  the 
coronal  suture,  crossing  the  groove  for  the  middle  menin- 
geal artery,  and  terminating  in  the  floor  of  the  left  middle 
fossa;  short  indirect  fissures  in  both  orbital  plates,  punc- 
tate extravasations  in  the  left  petrous  portion,  and  general 
hyperaemia  of  the  left  middle  fossa ;  no  epidural  or  cortical 
hemorrhage,  and  no  cerebral  laceration ;  pial  hemorrhage 
covering  the  left  hemisphere,  the  clot  very  thick  in  the 


474  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

midparietal  region,  and  a  separate  pial  extravasation 
thinly  covering  the  inferior  surface  of  the  cerebellum ;  no 
hemorrhage  upon  the  inferior  cerebral  surface  ;  cortical  con- 
tusion of  the  third  right  temporal  convolution  in  its  middle 


Fig.  45. — Indirect  Fractures  of  Orbital  Plates,  and  Contusion  of  Petrous  Portion  and 
Middle  Fossa,  with  Direct  Fracture  of  Base  and  Vertex. 

part;  minute  contusions  of  inferior  surface  of  the  left  tem- 
poral lobe  and  of  the  first  right  orbital  convolution  ;  moder- 
ate hypersemia  and  excessive  oedema  of  all  parts  of  the 
brain. 

Case  CXXVI.     Symptoms. — Patient  struck  by  an  un- 
known instrument  just  below  the  left  ear,  inflicting  two 


CASES    VERIFIED    BY    NECROPSY.  475 

wounds,  ^vllicll  had  bled  profusely.  On  admission  to  the 
hospital  he  was  not  wholly  conscious,  but  could  be  aroused 
sufficiently  to  recognize  and  curse  his  wife.  Temperature, 
97.6°;  pulse,  78;  respiration,  28;  deep  lacerated  wound 
below  left  ear,  and  superficial  wound  over  left  mastoid 
process ;  no  paralysis ;  loss  of  faecal  and  urinary  control. 
In  fourteen  hours  restlessness  and  muttering  delirium,  and 
in  eighteen  hours  paralysis  of  the  whole  right  upper  ex- 
tremity, which  on  the  second  day  extended  to  the  right 
side  and  lower  extremity,  and  at  the  end  of  fort3'-eight 
hours  to  the  right  side  of  the  face ;  pupils  insensitive  to 
light.  Death  occurred  at  the  end  of  four  daj's;  conscious- 
ness entirely  lost  on  the  second  da}' ;  right  patellar  reflex 
increased  ;  left  normal ;  abdominal  and  cremasteric  reflexes 
lost ;  lack  of  faecal  and  urinary  control  continued.  Tempera- 
ture, 97.6°  on  admission;  declined  to  96.8''  in  tAvo  hours, 
and  rose  to  98.8°  in  five  hours;  then  remained  at  ioi°-[- 
till  the  last  day,  when  it  rose  to  103.4°,  104.2°,  with  imme- 
diate post-mortem  recession;  pulse,  78  to  136;  respiration, 
20  to  56. 

Lesions. — Fracture  and  partial  dislocation  of  second  cer- 
vical vertebra ;  no  lesion  of  spinal  cord.  No  fracture  of 
skull;  no  epidural  hemorrhage;  no  laceration  of  brain. 
Large  pial  hemorrhage  covering  left  hemisphere ;  limited 
central  contusion  of  left  occipital  lobe,  oval,  well  defined, 
and  markedl}^  softened ;  some  punctate  extravasations  in 
posterior  part  of  same  lobe ;  moderate  general  hyper2;mia 
and  oedema. 

Case  CXXVII.  Symptoms. — Patient  struck  upon  the 
head  by  a  falling  timber;  primary  and  permanent  uncon- 
sciousness. On  immediate  admission  to  the  hospital, 
hemorrhage  from  left  ear  and  nostril  and  from  mouth; 
pupils  moderately  dilated,  and  radial  pulsations  symmet- 
rical; no  muscular  symptoms.  Temperature,  98.2°; 
pulse,  58;  later,  52;  respiration,  5.  Death  in  thirty  min- 
utes from  time  of  injury.  Respiration  was  five  in  the 
minute  from  first  observation  made  bv  the  ambulance  sur- 


476  INJURIES    OF    THE   BRAIN   AND    MEMBRANES. 

geon  before  admission,  and  was  not  more  than  three  in 
articulo  mortis;  each  act  was  of  an  explosive  character. 

Lesions. — Necropsy  four  hours  post  mortem.  Large 
scalp  wound  above  left  ear,  and  flap  raised  from  temporal 
fascia;  right  half  of  coronal  suture  separated,  with  con- 
tinuous open  fissure  beginning  at  median  line  and  extend- 
ing through  left  middle  fossa  and  middle  of  petrous 
portion  into  foramen  magnum  ;  a  branch  of  this  fissure 
ran  from  the  middle  fossa  through  the  sphenoid  body ; 
thick  clot  covered  the  whole  vertex ;  no  epidural  hemor- 
rhage ;  well  marked  contusion,  with  softening  and  punctate 
extravasations,  of  the  middle  portion  of  the  second  left 
temporal  convolution  ;  no  cerebral  laceration  ;  fluid  blood 
covered  the  whole  brain  surface  and  was  in  large  quantity 
in  the  middle  and  posterior  basic  fossae ;  general  hyper- 
semia  of  the  brain  and  excessive  oedema,  with  punctate 
extravasations  in  both  corpora  striata  and  in  the  optic 
thalamus. 

Case  CXXVIII.  Syviptouis. — Primary  and  permanent 
unconsciousness  following  a  fall  of  twenty  feet ;  stertor, 
left  subconjunctival  hemorrhage  with  oedema  of  the  lids, 
slightly  dilated  pupils,  haematoma  in  left  parieto-occipital 
region,  radial  pulsations  symmetrical,  and  no  muscular 
derangements.  On  admission  to  hospital,  face  very  cya- 
notic with  occurrence  of  severe  paroxysms  of  coughing  and 
choking;  thirty  minutes  later,  temperature,  94.2'^ ;  pulse, 
76;  respiration,  24;  moderate  hemorrhage  from  left  nos- 
tril, breathing  very  noisy,  and  vomiting  which  endangered 
life  by  reason  of  paralysis  of  the  pharyngeal  muscles;  five 
hours  later  still,  left  radial  pulse  small  and  rapid,  right 
full  and  slow;  right  pupil  dilated,  left  contracted;  breath- 
ing still  noisy;  no  change  in  condition  till  death  at 
end  of  twelve  hours.  The  temperature  rose  progressively 
to  105.4°,  with  post-mortem  recession  in  thirty  minutes  to 
105°;  pulse,  64  to  94;  and  respiration,  28  to  30. 

Lesions. — Linear  fracture  extending  from  left  posterior 
parietal   region   through   middle   fossa  into  orbital  plate; 


CASES   VERIFIED    BY   NECROPSY.  477 

large  epidural  hemorrhage  covering  cerebral  vertex  and 
base  in  left  parietal  and  frontal  regions ;  laceration  of  both 
temporal  lobes  inferiorly  and  laterally ;  cortical  and  pial 
hemorrhages  over  whole  vertex  and  extending  into  middle 
and  posterior  fossae ;  excessive  general  hyperaemia  and 
oedema  of  the  brain  substance. 

Fractures  of  the  Cranial  Base  from  Pistol-Shot 

Wound. 

Case  CXXIX.  Symptoms. — Consciousness  lost  but  re- 
gained before  admission  after  suicidal  pistol-shot  wound  of 
the  head ;  total  loss  of  vision  ;  exophthalmia  of  both  eyes ; 
dilatation  of  both  pupils,  which  were  irresponsive  to  light ; 
temperature,  100.2°;  pulse,  60;  respiration,  20.  Ophthal- 
mic examination  by  Dr.  P.  A.  Callan  on  the  second  day 
disclosed  only  patches  of  retinal  hemorrhage ;  mental 
condition  unimpaired ;  sense  of  smell  entirely  lost.  On 
the  fourth  day  an  unsuccessful  attempt  was  made  to  ex- 
tract the  ball,  and  a  drainage-tube  was  carried  from  the 
foyer  of  entrance  through  both  frontal  lobes  to  a  cranial 
opening  made  upon  the  opposite  side;  followed  for  five 
days  by  discharge  of  brain  tissue,  and  then  till  death  by 
pus  in  increasing  quantity.  Mental  condition  normal  till 
the  fifth  day,  sluggish  till  the  ninth  day,  and  afterward 
marked  by  increasing  delirium,  w^hich  lapsed  into  a  mut- 
tering stupor  at  the  end  of  life  on  the  thirteenth  day. 
Temperature  at  time  of  operation,  99°;  rose  to  103.6°  in 
ensuing  twenty-four  hours,  and  then  varied  from  102.4° 
to  104.5°  on  the  last  day;  pulse  and  respiration  nearly 
normal  till  just  before  death. 

Lesions. — Ball  penetrated  external  wall  of  right  orbit, 
just  behind  external  .angular  process;  passed  beneath  op- 
tic nerve,  comminuted  inner  wall  of  orbit,  crista  galli, 
cribriform  plate,  and  lesser  wing  of  sphenoid;  entered 
left  orbit  through  inner  wall,  and  was  found  beneath 
left   optic   nerve.     In    the    cranial    cavity  its    course   was 


478  INJURIES    OF   THE   BRAIN   AND    MEMBRANES, 

beneath  both  optic  nerves.  Subarachnoid  purulent  ef- 
fusion covered  both  frontal  lobes,  more  copious  on  left 
side  and  at  base;  left  frontal  lobe  excavated,  and  filled 
with  pus  and  brain  detritus.  Pus  also  existed  in  the 
track  of  the  drainage  tube  through  the  right  frontal  lobe. 

Case  CXXX.  Syniptoms. — Pistol-shot  wound;  imme- 
diate unconsciousness :  rapid  and  feeble  pulse ;  sighing 
respiration ;  profuse  hemorrhage  from  wounds  of  entrance 
and  exit.     Death  within  an  hour. 

Lesions. — Pistol-shot  fracture  of  right  frontal  bone 
through  temporal  fossa;  ball  grazed  the  outer  and  pos- 
terior part  of  the  orbital  plate  and  fractured  the  right 
lesser  wing  of  the  sphenoid,  grooved  the  inferior  surface 
of  both  frontal  lobes  just  anterior  to  the  fissures  of  S3dvius, 
destroying  the  cortex  and  subcortex  for  a  space  three- 
fourths  of  an  inch  in  width,  and  emerged  through  the  left 
temporal  fossa  at  a  little  higher  level  than  the  point  of  en- 
trance. The  vertex  and  base  were  fissured  from  the  point 
of  exit,  and  the  coronal  and  biparietal  sutures  divulsed 
and  widely  separated.  The  whole  surface  of  the  brain 
was  covered  by  a  thin  subarachnoid  hemorrhage,  which 
was  partly  cortical  and  partly  pial.  The  brain  substance 
generally  was  markedly  hypersemic  and  its  minute  vessels 
were  filled  with  coagula.  The  corpora  striata  and  optic 
thalami,  especially  the  striata,  were  much  contused,  their 
substance  studded  with  punctate  extravasations,  and  their 
vessels  distended  with  thrombi.  The  pons,  medulla,  and 
cerebellum  were  but  slightly  altered. 

Case  CXXXI.  Symptoms. — Pistol-shot  wound  through 
right  temporal  fossa ;  cutaneous  opening  small  and  circu- 
lar; consciousness  permanently  lost;  pupils  dilated,  the 
right  slightly  the  larger ;  left  corneal  reflex  absent ;  urine 
retained;  some  pulmonary  oedema;  temperature  on  ad- 
mission, 96.4°,  and  from  96.8°  to  96°  for  five  hours,  then 
declined  to  95.6°;  pulse  on  admission,  85 — subsequently 
from  94  to  80;  respiration  on  admission,  14 — for  an  hour 
and  a  half,  12  ;  in  two  hours  and  a  half,  10;  in  three  hours. 


CASES   VERIFIED    BY    NECROPSY.  479 

8  ;  in  four  hours  and  a  half,  6 ;  in  five  hours,  4 ;  and  in  artic- 
ulo  mortis,  a  few  moments  later,  2.  Cardiac  action  contin- 
ued three  minutes  after  respiration  ceased. 

Lesions. — Ball  entered  the  cranial  cavity,  severing  the 
trunk  of  the  middle  meningeal  artery,  passed  through  the 
third  right  temporal  convolution,  and  was  lodged  in  the 
posterior  part  of  the  inner  border  of  the  right  temporo- 
sphenoidal  lobe.  A  small  piece  of  bone,  driven  in  ad- 
vance of  the  ball,  was  found  between  the  right  lateral 
columns  of  the  medulla.  A  large  arachnoid  clot,  probably 
in  part  epidural  and  in  part  cortical,  filled  the  middle  fossa, 
spread  over  the  whole  right  hemisphere,  and  thickly  cov- 
ered the  pons  and  medulla,  Hyperaemia  of  the  right 
hemisphere  and  basic  ganglia  was  of  considerable  intensity. 

Case  CXXXII,    Symptoms. — None ;  patient  found  dead. 

Lesions.  —  Large  lacerated  pistol-shot  wound  in  right 
temporal  region;  temporal  muscles  burned  and  disinte- 
grated for  some  distance  from  the  cutaneous  opening. 
The  ball  passed  through  both  frontal  lobes,  comminuted 
both  orbital  and  intervening  cribriform  plates,  and  emerged 
through  left  temporal  fossa.  The  calvarium  was  separated 
from  the  supraorbital  ridges  and  broken  into  large  loose 
fragments  in  its  anterior  portion. 

Case  CXXXITI.  Symptoms.  —  Suicidal  pistol-shot 
wound;  ball  entered  just  below  the  right  ear  and  in  front 
of  the  mastoid  process,  and  was  lodged  in  the  petrous  por- 
tion of  the  temporal  bone ;  removed  on  the  following  day ; 
delirium  and  rise  of  temperature  on  the  sixth  day,  flexion 
of  the  right  leg  on  the  thigh  on  the  eighth  day,  and  death 
on  the  fourteenth  day. 

Lesions. — Fracture  of  anterior  surface  of  the  right  pe- 
trous portion,  epidural  and  cortical  hemorrhage  at  that 
point,  pial  hemorrhage  over  left  occipital  lobe  and  left 
motor  area,  and  laceration  of  the  temporo-sphenoidal  lobe 
at  the  site  of  fracture. 

Case  CXXXIV.  Symptoms. — Suicidal  wound  through 
the  anterior  cervical  region;  ball  of  0.38  cal.  entered  in 


480  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

the  median  line  over  the  larynx ;  no  hemorrhage  from  the 
wound  or  mouth  ;  immediate  partial  aphonia ;  deglutition 
of  liquids  only  possible,  and  with  difficulty ;  hemorrhage 
from  the  left  ear.  On  the  third  day,  deglutition  impossible 
and  mental  condition  stupid;  followed  by  delirium  requir- 
ing mechanical  restraint  on  the  fourth  day,  and  on  the 
fifth  day  by  paresis  of  right  arm,  hand,  and  lower  ex- 
tremity, and  loss  of  fascal  and  urinary  control,  with  some 
improvement  in  voice  and  power  of  deglutition.  On  the 
sixth  day  there  was  added  right  facial  paralysis  Avith  pto- 
sis; the  right  pupil  was  dilated  and  the  left  contracted, 
and  the  urine  was  controlled.  The  temperature  on  ad- 
mission was  100"^,  rose  on  the  second  day  to  101°,  on  the 
third  day  to  102.4°,  ^.nd  on  the  fourth  day  to  103.6°;  later 
it  attained  an  elevation  of  107.6°.  The  pulse  was  from  70 
to  86  till  the  fourth  day, when  it  rose  to  132.  The  respira- 
tion was  normal  for  four  days  and  became  frequent  only 
at  a  late  period.     Death  occurred  on  the  seventeenth  day. 

Lesions. — Bullet  was  lodged  in  the  apex  of  the  left  pe- 
trous portion;  small  fragment  of  bone  driven  upward 
about  an  eighth  of  an  inch ;  no  lacerations ;  large  pial 
hemorrhage,  in  greatest  amount  over  left  fissure  of  Ro- 
lando; large  subarachnoid  serous  effusion. 

Case  CXXXV.     Symptoms. — Patient  found  dead. 

Lesions. — Right  pupil  moderately  dilated,  the  left  nor- 
mal. External  wound  behind  the  external  angular  proc- 
ess, one  and  one-half  inches  in  length,  linear,  and  its 
lower  border  retracted  three-fourths  of  an  inch  and  slightly 
torn,  exposing  the  blackened  and  lacerated  muscular  tissue 
below  the  temporal  fascia,  and  its  edges  burned.  There 
was  no  ingraining  of  the  skin  with  powder,  no  burning, 
and  no  smoke  stain ;  no  free  grains  upon  the  surface.  The 
subcutaneous  blackened  area  was  one  and  three-fourths 
inches  in  diameter,  and  was  entirely  below  the  temporal 
fascia.  The  osseous  entrance  was  large,  circular,  and 
finely  fissured,  and  was  situated  in  the  temporal  fossa  at 
the  level  of    the  zygoma.      The  ball  of  0.38  cal.   passed 


CASES   VERIFIED    BY    NECROPSY.  48 1 

through  both  temporal  lobes  in  their  inferior  portion,  sev- 
ering the  pons  anteriorly,  and  made  exit  through  the  left 
squamous  portion,  which  with  the  petrous  portion  was 
much  comminuted.  The  ball  was  found  among  the  bony 
fragments.  The  brain  substance  was  hyperaemic  and 
oedematous,  and  its  vessels  contained  minute  thrombi. 
Unburned  grains  of  powder  were  found  in  the  right  tem- 
poral lobe. 

Case  CXXXVI.  Symptoms. — None  recorded;  patient 
died  in  the  ambulance. 

Lesions. — Both  pupils  widely  dilated.  Ball  entered 
through  left  upper  eyelid ;  brain  matter  in  external 
wound ;  widely  scattered  grains  of  powder  embedded  over 
whole  left  side  of  face,  from  chin  to  margin  of  hair, 
and  a  few  in  right  cheek  and  upper  eyelid ;  no  burn- 
ing of  the  skin ;  wound  contused  and  edge  lead  stained ; 
one  or  two  fragments  of  lead  in  muscle  of  eyelid.  The 
osseous  entrance  involved  the  supra-orbital  ridge  and 
the  ball  in  its  course  carried  away  the  inner  fourth  of  the 
orbital  plate.  The  ball  passed  through  the  left  frontal 
and  parietal  lobes  to  the  parieto-occipital  junction  and  was 
lodged  in  the  cortex  at  the  vertex.  No  powder  grains 
were  discoverable  in  the  brain  track,  and  only  two  or  three 
fragments  of  bone,  which  were  found  in  the  prefrontal 
lobe.  The  whole  surface  of  the  brain  was  covered  with 
blood,  mainly  fluid,  and  a  clot  one-fourth  of  an  inch  in 
thickness  compressed  the  pons  and  anterior  part  of  the 
medulla ;  brain  substance  hyperaemic  and  oedematous ; 
heart  contracted  ;  lungs  oedematous. 

Case  CXXXVII.  Symptoms.  — "^uWq^  of  0.38  cal. 
•entered  the  forehead  a  little  to  the  left  of  the  median  line, 
about  two  inches  above  the  glabella;  no  superficial  lesions ; 
edge  of  the  wound  blackened;  primary  and  permanent 
unconsciousness;  stertor;  projectile  vomiting,  which  ceased 
on  admission  to  the  hospital;  arms  flexed  and  drawn 
across  the  chest,  and  thumbs  and  fingers  clenched ;  occa- 
sional spasmodic  movements  of  the  shoulders ;  eight  hours 
31 


482  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

later  two  or  three  general  convulsions ;  pupils  symmetri- 
cally contracted;  final  pulmonary  oedema  and  death  in 
sixteen  hours.  Temperature  on  admission,  97.8°;  pulse, 
52;  in  five  hours,  temperature,  98°;  in  eight  hours,  98.2°; 
and  in  sixteen  hours,  101°,  with  immediate  post-mortem  in- 
crease to  101.4°. 

Lcsious. — The  lower  margin  of  the  osseous  wound  was 
one  and  one-half  inches  above  the  glabella,  and  was  three- 
fourths  of  an  inch  in  diameter  in  the  outer  and  one  inch 
in  the  inner  table;  bone  very  thick  and  not  fissured;  two 
indirect  small  stellate  fractures  in  the  right  orbital  plate, 
one  near  the  ethmoid  margin  and  one  near  the  lesser  sphe- 
noidal wing ;  another  indirect  stellate  fracture  in  the  left 
orbital  plate  with  a  long  fissure  extending  toward  its  outer 
part.  The  bullet  entered  the  superior  median  fissure  of 
the  brain,  lacerating  both  frontal  lobes,  traversed  the  right 
hemisphere  just  below  the  cortex,  and  rested  upon  the  sur- 
face of  the  right  occipital  lobe  near  the  median  line ;  dura 
mater  and  bone  uninjured;  track  filled  with  blood;  six 
osseous  fragments  driven  into  the  frontal  lobes;  fornix 
contused ;  cortical  hemorrhage  thickly  covered  both  hemi- 
spheres and  filled  the  frontal  sulci ;  pia  mater  exceedingly 
hypersemic. 

Case  CXXXVIII.  Sj'w//^;//^.— Patient  admitted  to 
hospital  immediately  after  the  infliction  of  a  pistol-shot 
wound  three-fourths  of  an  inch  above,  and  one-fourth  of 
an  inch  behind,  right  external  angular  process.  The 
wound  was  one-fourth  of  an  inch  in  diameter,  circular,  pa- 
tulous, lacerated,  and  having  its  margin  burned  to  the  width 
of  one-eighth  of  an  inch.  The  skin  was  denuded  by  blis- 
tering in  an  area  of  one  and  one-fourth  inches  by  three- 
fourths  of  an  inch  anteriorly,  and  in  another  area  of  three- 
fourths  of  an  inch  inferiorly.  There  was  a  smoke  stain  of 
two  inches  antero-posteriorly  by  one  and  one-half  inches 
vertically.  No  free  or  embedded  unburned  grains  of  pow- 
der were  visible,  and  there  was  no  brain  matter  in  the 
wound.     The  exit  was  two  inches  in  diameter,  and  was 


CASES   VERIFIED    BY    NECROPSY.  483 

two  and  one-fourth  inches  above  the  left  ear,  and  lacer- 
ated, everted,  and  containing  brain  substance.  The  tem- 
perature was  101°;  pulse,  60;  and  respiration,  5;  skin  pale 
but  warm  and  flushing  at  times ;  profound  unconsciousness, 
which  continued  till  death ;  right  pupil  dilated,  left  con- 
tracted, and  both  irresponsive  to  light ;  ecchymosis  of  both 
eyes,  and  oedema  of  both  conjunctivae;  eyes  bulging  and 
pulsating  on  palpation ;  pulse  slow,  full,  compressible,  and 
intermittent;  respiration  deep,  stertorous,  and  its  rate  five 
in  the  minute  when  quiet,  but  twenty  or  more  when  dis- 
turbed ;  loss  of  urinary  control ;  convulsions  involving 
upper  extremities,  and  at  times  general;  three  in  the  first 
hour,  and  two  subsequently;  hemorrhage  from  nose, 
mouth,  right  ear,  and  from  wounds  of  entrance  and  exit. 
Both  pupils  became  dilated.  The  temperature  rose  pro- 
gressively in  six  hours  to  106°,  and  then  declined  to  103.2° 
at  death  two  hours  later;  the  pulse  increased  to  124,  and 
the  respiration  at  the  end  of  the  first  hour  was  36,  and  did 
not  become  less  frequent  afterward.  The  heart  continued 
to  pulsate  for  three  minutes  post  mortem. 

Lesions. — Both  pupils  dilated.  Superficial  fascia  sepa- 
rated about  wound  of  entrance  from  the  fibres  of  a  very 
thick  occipito-frontalis  muscle,  which  was  blackened  over 
an  area  of  one  inch  anteriorly,  and  of  one-half  inch  pos- 
teriorly; ball  track  concealed  in  the  substance  of  an  enor- 
mously thick  temporal  muscle,  which  contained  grains  of 
unburned  powder;  haematoma  of  the  left  side  of  the  head, 
and  hemorrhage  into  both  temporal  muscles;  osseous  en- 
trance circular,  and  not  comminuted  or  fissured ;  contigu- 
ous surfaces  of  calvarium  and  dura  mater  powder  stained 
over  an  area  of  one  inch ;  cortical  hemorrhage  over  the 
whole  of  left  hemisphere,  which  had  reached  the  arachnoid 
cavity  and  filled  all  the  basic  fossse ;  clot  upon  the  right 
side  of  the  pons,  and  detached  coagula  upon  the  right  side 
of  the  medulla.  The  ball  in  its  passage  had  fractured 
both  orbital  plates  and  the  body  of  the  ethmoid,  and  the 
orbital  vessels  were  surrounded  by  a  thick  clot,  which  ex- 


484  IN'TURIES   OF   THE    BRAIN   AND    MEMBRANES. 

tended  into  the  orbital  connective  tissue.  The  brain  was 
extensively  lacerated  in  the  track  of  the  ball,  which  was  of 
38  cal.  ;  the  parts  involved  were  the  inferior  portion  of 
the  anterior  half  of  the  right  temporal  and  of  the  poste- 
rior half  of  the  right  frontal  lobes,  and  the  greater  portion 
of  both  corpora  striata,  and  rather  less  of  the  left  temporal 
and  frontal  lobes.  The  posterior  margin  of  the  laceration 
on  the  right  side  was  bordered  by  an  area  of  localized  con- 
tusion with  punctate  extravasations.  There  was  much 
comminuted  bone  in  the  right  side  of  the  brain,  but  dis- 
integration was  too  complete,  and  hemorrhage  too  great, 
to  determine  the  existence  of  grains  of  powder.  A  cylin- 
drical clot,  the  size  of  a  goose  quill,  extended  from  en- 
trance to  exit,  which  was  just  above  the  left  fissure  of 
Sylvius,  and  externalh'  two  inches  above  the  ear.  The 
brain  substance  was  moderately  hyperaemic,  Vvdth  thrombi 
in  the  minute  vessels. 

Case  CXXXIX.  Symptoms.  —  Xone ;  subject  found 
dead. 

Zt'^/t?;w,— Entrance  of  ball  circular,  and  one-half  inch 
behind  right  external  angular  process ;  diameter  one-eighth 
of  an  inch ;  moderate  hemorrhage  over  side  of  face  and 
ear,  which  had  remained  undisturbed ;  no  trace  of  smoke 
or  of  brain  spatter;  no  unburned  grains  of  powder,  either 
free  or  embedded;  edge  of  wound  burned,  and  a  circular 
burned  area,  seven-eighths  of  an  inch  in  diameter;  skin 
black,  smooth,  and  like  parchment;  included  in  a  scorched 
area  of  one  and  seven-eighths  inches  by  one  inch;  pupils 
symmetrical  and  slightly  contracted ;  large  extravasation 
of  blood  in  the  deeper  layers  of  the  scalp  over  the  frontal 
and  parietal  regions.  The  ball  entered  the  cranial  cavity 
through  the  floor  of  the  right  middle  fossa  just  beneath 
the  lesser  wing  of  the  sphenoid  bone,  passed  through  the  left 
lateral  ventricle,  and  the  left  parietal  lobe  just  above  the 
horizontal  fissure  of  Sylvius,  fractured  the  parietal  bone 
below  the  parietal  eminence,  everted  its  fragments,  and 
rested  in  the  osseous  wound.     There  was  a  powder  stain 


CASES   VERIFIED    BY   NECROPSY.  485 

in  an  area  of  three-eighths  of  an  inch  in  diameter  below 
the  temporal  fascia.  The  brain  track  was  three-fourths  of 
an  inch  in  width,  and  contained  no  visible  grains  of  pow- 
der or  fragments  of  bone.  There  was  moderate  cortical 
hemorrhage  over  the  right  hemisphere  and  base  of  the 
brain,  and  moderate  general  cerebral  hyperaemia. 

Case  CXL.  Syuiptoins. — None  recorded;  died  while 
being  taken  to  the  ambulance. 

Lesions. — Cutaneous  entrance  one-eighth  of  an  inch  in 
diameter,  three-fourths  of  an  inch  above  right  external 
angular  process;  no  smoke  stain,  no  brain  spatter,  no  un- 
burned  grains  of  powder  upon  the  surface ;  eyebrow  and 
subjacent  skin  slightly  scorched ;  an  area  of  sparsel}'  em- 
bedded powder  grains,  seven  inches  by  six  inches,  over 
the  ear,  side  of  the  forehead  and  face,  including  the  nose 
as  far  as  the  line  of  the  nostril ;  one  or  two  grains  in  the 
conjunctiva,  and  two  in  the  neck ;  only  moderate  external 
hemorrhage,  and  subcutaneous  hemorrhage,  in  an  area  of 
one  inch  in  diameter,  above  and  below  the  temporal  fascia ; 
pupils  normal.  The  ball  penetrated  the  cranial  cavity  just 
above  the  right  orbital  plate,  passed  obliquely  backward 
from  the  anterior  extremity  of  the  right  fissure  of  Sylvius, 
across  the  frontal  lobe  and  through  the  tip  of  the  left  tem- 
poral lobe,  making  a  furrow  in  the  cerebral  cortex  three- 
eighths  of  an  inch  in  depth,  which  contained  no  appreci- 
able grains  of  powder  or  fragments  of  bone ;  no  epidural 
hemorrhage ;  cortical  hemorrhage  in  moderate  amount 
over  right  hemisphere,  but  in  greater  quantity  at  the  base ; 
pons  and  medulla  covered  with  clot;  moderate  cerebral 
hyperaemia  with  minute  thrombi.  The  osseous  exit  was  one 
inch  behind  the  left  external  angular  process  of  the  fron- 
tal, and  comminuted  the  squamous  portion  of  the  temporal 
bone  in  a  space  one  inch  in  diameter;  it  also  fissured  the 
external  portion  of  the  left  orbital  plate  and  the  floor  of 
the  middle  fossa.  The  cutaneous  exit  was  one-fourth  of 
an  inch  in  diameter,  and  slightly  lacerated,  with  moderate 
hemorrhage  above  and  below  the  temporal  fascia. 


486  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

Case  CXLI.     Symptoms. — None;  death  immediate. 

Lesions. — Ball  entered  the  mouth,  penetrated  the  left 
palate  process  of  the  superior  maxilla  and  body  of  the 
sphenoid  bone  anteriorly,  entered  the  cranial  cavity 
through  the  superior  sphenoidal  surface  without  commi- 
nuting the  bone,  traversed  the  left  frontal  lobe,  left  lateral 
ventricle,  and  left  parietal  lobe,  fractured  the  parietal  bone 
near  the  median  line,  and  fell  back  beneath  the  cortex.  A 
small  triangular  piece  of  the  parietal  bone  was  elevated, 
and  covered  by  a  hsematoma  of  the  scalp.  The  brain 
track  was  nearly  vertical,  inclining  a  little  backward,  one- 
half  inch  in  width,  and  containing  no  evident  unburned 
grains  of  powder  or  fragments  of  bone.  The  brain  sub- 
stance was  moderately  hypersemic.  The  ball  was  of  0.32 
cal.     The  pupils  were  very  slightly  dilated. 

Case  CXLII.  Symptoms. — Patient  found  unconscious 
and  breathing  heavily;  death  occurred  soon  afterward. 

Lesions. — Both  pupils  dilated  ;  hemorrhage  from  mouth 
and  left  nostril  and  from  a  wound  one  and  one-half  inches 
behind  right  external  angular  process.  Cutaneous  wound 
was  circular,  one-half  inch  in  diameter,  with  its  edges 
burned,  and  contained  brain  matter.  There  was  no  burn- 
ing of  the  skin,  smoke  stain,  or  unburned  grains  of  pow- 
der upon  the  surface.  There  was  a  large  hsematoma  in 
the  right  fronto-parietal,  and  another  in  the  left  parietal 
reofion.  The  temporal  fascia  was  blackened,  and  also  an 
area  one  inch  in  diameter  in  the  temporal  muscle.  The 
osseous  entrance  was  circular,  and  a  fissure  extended 
from  it  through  the  frontal  bone  just  above  the  right 
supra-orbital  ridge,  into  the  left  orbital  plate,  which  was 
comminuted.  The  ball  passed  through  both  frontal  lobes 
and  the  left  parietal  lobe,  fractured  the  bone  about  the 
parietal  eminence,  and  dropped  back  to  a  point  just  be- 
neath the  cortex.  An  osseous  fragment  one  inch  square 
was  elevated  but  not  detached,  and  was  covered  by  the  left 
parietal  hsematoma  previoush'  noted.  The  ball  track,  of 
large  size,  in  the  right  frontal  lobe  contained  some  finely 


CASES   VERIFIED    BY   NECROPSY.  487 

comminuted  bone  and  one  or  tAvo  appreciable  grains  of 
powder,  and  showed  a  bluish  stain.  There  were  only  a 
slight  cortical  hemorrhage  and  moderate  general  hy- 
peraemia.      Ball  of  0.32  cal. 

Case  CXLIII.  Synipto^is. — Homicide;  woman,  aged 
tw^enty-nine  years,  shot  twice  in  the  head  at  short  range ; 
no  loss  of  consciousness.  On  immediate  admission  to  the 
hospital,  mental  condition  normal;  pain  in  head  and  neck; 
wound  one  and  one-half  inches  above,  and  a  little  behind, 
left  external  angular  process,  with  area  of  finely  ingrained 
powder  three-fourths  of  an  inch  in  diameter ;  no  burn  of 
hair  or  skin ;  subcutaneous  tissues  blackened  in  area  of 
three-fourths  of  an  inch  through  temporal  muscle ;  bullet 
of  0.32  cal.  extracted  from  the  surface  of  temporal  bone; 
second  wound  two  inches  below  and  a  little  behind  left  mas- 
toid process,  in  which  the  bullet  could  not  be  detected  by  the 
probe.  For  four  days  there  were  no  symptoms  of  impor- 
tance. Pain  in  the  head  was  confined  to  the  neighborhood  of 
injuries,  and  was  attended  by  stiffness  of  the  neck  and  some 
discharge  from  the  posterior  wound.  Vomiting,  which 
occurred  from  time  to  time,  was  notable  onl}'  on  the 
fourth  night,  when  it  was  frequent  and  the  matter 
vomited  contained  mucus  and  a  greenish  fluid.  There 
was  no  vomiting  later,  and  the  bowels  were  moved  only 
by  enema  till  just  at  the  end  of  life.  On  the  fifth  day 
temperature  rose  from  101°-^  to  104.4°,  ^^^^  oi^  the  sixth 
was  1 03.8°- 1 04°,  though  the  patient  felt  well.  On  the 
seventh  day  slight  delirium  was  continuous  with  a  throb- 
bing sensation  in  the  head,  and  the  temperature  in  the 
early  morning  fell  to  102°- 102. 8°.  The  pulse  in  this  time 
had  only  twice  exceeded  100.  From  the  eighth  to  the 
eleventh  days  inclusive,  delirium  was  constant  but  not 
violent,  urinary  control  was  lost,  and  there  was  but  little 
discharge  from  the  wounds ;  the  temperature  varied  from 
105°  to  102.6°  and  the  pulse  from  no  to  132.  On  the 
twelfth  day  there  was  less  delirium,  and  some  rational 
response    to   questions;    temperature   fell  to    101.4°.      On 


488 


IX JURIES    OF   THE    BRAIX   AND    MEMBRANES. 


the  thirteenth  day,  flushing  of  the  face,  drowsiness,  and 
continued  lack  of  urinary  control,  with  temperature  of 
1 03.8°- 104''.  On  the  fourteenth  day  a  bullet  was  detected 
in  the  posterior  wound  and  a  fragment  removed ;  temper- 
ature, io2°-| — 102°.  On  the  fifteenth  day  the  patient  was 
semi-conscious  and  the  bowels  moved  continuoush'  with- 
out control;  temperature,  i03°-|--      Oi^  the  sixteenth  day 


Fig.  46. — Depression  of  External  Table  -with  the  Anterior  Wound. 


complete  unconsciousness,  muscular  twitchings  in  all  the 
extremities;  temperature,  i03.8°-i04.6°.  On  the  seven- 
teenth day,  temperature  108""  to  109.4''  at  the  time  of  death, 
with  post-mortem  recession  in  thirty  minutes  to  109°. 

Lesions. — Ingrained  powder  had  been  washed  out  from 
the  skin  about  the  wound  in  the  temporal  region  by  the 
use  of  dressings  in  the  progress  of  the  case ;  depression  in 
the  left  temporal  bone  immediately  below  the  temporal 
ridge   in  its  anterior  portion    (Fig.   46),  which  was  filled 


CASES    VERIFIED    BY   NECROPSY. 


489 


with  pus  ;  inner  table  comminuted  and  depressed  in  an  area 
of  three-fourths  of  an  inch  (Fig.  47)  ;  skull  very  thick. 
The  bullet,  which  entered  the  posterior  cervical  region,  was 
found  loosely  embedded  in  the  bone  of  the  left  basic  fossa, 
with  its  anterior  extremity  covered  by  fragments  of  the  inner 
table  projecting  into  the  cranial  cavity  near  the  foramen 
magnum  (Figs,  48,  49).     Xo  meningeal  effusions;  cerebral 


Fig.  47.— Comminution  of  the  Inner  Table  with  the  Anterior  Wound. 


surface  notably  dry ;  no  intracranial  hemorrhages ;  contu- 
sion of  brain  in  middle  of  third  left  frontal  convolution, 
one-half  inch  in  diameter,  at  site  of  anterior  osseous  depres- 
sion ;  another  contusion  of  the  same  diameter  in  the 
centre  of  inferior  surface  of  left  cerebellar  lobe,  corre- 
sponding to  side  of  posterior  osseous  depression ;  both 
sharply  limited  and  confined  to  cortex;  moderate  general 
hyperaemia  and  oedema. 

Case    CXLIV.     Syinptoms. — Xone    noted;    death    in   a 
few  moments. 


490 


IXTURIES    OF   THE    BRAIN    AND    MEMBRANES. 


Lesions. — Ball  of  0.32  cal.  entered  one-half  inch  be- 
hind and  one-eighth  inch  below  right  external  angular 
process;  not  much  external  hemorrhage;  black  area  of 
five-eighths  inch  diameter  in  a  smoke  area  of  one  inch 
diameter;  external  wound  one-eighth  inch  diameter;  no 
subcutaneous  hemorrhage;  funnel-shaped  black  area  in 
temporal  muscle  one-half  inch  diameter  at  temporal  fascia; 


Fig.  4S.— Direct  Fracture  of  Base  with  the  Posterior  Wound.    External  Table. 


osseous  wound  one-fourth  inch  diameter  in  temporal  bone 
just  above  level  of  zygoma,  circular,  and  without  Assuring 
or  comminution ;  small  osseous  fragment  lying  upon  the 
dura  mater;  ball  passed  through  fissure  of  Sylvius,  diag- 
onally across  basal  surface  and  through  posterior  part 
of  left  temporal  lobe  nearly  to  cortex,  and  then  back- 
ward through  posterior  part  of  lateral  ventricle  to  a  lodge- 
ment in  the  posterior  and  external  part  of  the  occipital 
lobe  beneath  cortex.     The  ball    in   its  basilar  course  de- 


CASES   VERIFIED    BY    NECROPSY.  49 1 

tached  clinoid  processes  and  dorsum  ephippii;  osseous 
fragments  in  right  fissure  of  Sylvius  and  in  left  temporal 
lobe;  large  cortical  hemorrhage  over  whole  vertex  and 
in  central  basic  region. 

Case  CXLV.  Symptoms.  —  Patient  admitted  to  hos- 
pital two  days  after  reception  of  injury;  semi-conscious 
without  pain,  and  irritable;  he  spoke  very  slowly  but  cor- 


FlG.  49.— Direct  Fracture  of  Base  with  the  Posterior  Wound.    Inner  Table. 

rectly,  and  was  without  motor  symptoms.  There  was 
extensive  ecchymosis  of  both  eyes,  but  the  pupils  were 
normal,  and  there  was  no  subconjunctival  hemorrhage; 
increasing  stupor  and  final  coma.  Temperature,  106.2°. 
Death  in  twelve  hours. 

Lesions. — The  ball  passed  through  the  right  malar  bone 
at  the  root  of  the  zygomatic  process,  and  transversely 
through  both  frontal  lobes,  fracturing  both  orbital  plates 
and  cutting  off  the  crista  galli,  and  lodged  in  an  osseous 
depression  opposite  its   point  of  entrance.     Fissures  ex- 


492  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

tended  from  both  orbital  plates,  converged,  joined,  and 
extended  to  the  coronal  suture.  Both  prefrontal  lobes 
were  disintegrated;  there  was  no  epidural  hemorrhage 
and  no  burning  of  the  skin.     The  ball  was  of  0.32  cal. 

Case  CXLVI.  Symptoms. — Suicidal  wound  inflicted 
during  a  paroxysm  of  alcoholic  mania.  Ball  of  0.22  cal. 
entered  the  right  ear  at  contact;  consciousness  retained; 
a  single  mouthful  of  blood  ejected  soon  afterward ;  no 
ingrained  powder;  epidermis  removed  from  about  one 
square  inch  of  surface  in  front  of  the  ear;  membrana 
tympani  perforated ;  no  general  symptoms.  Through  a 
wound  in  the  anterior  wall  of  the  meatus  a  probe  could  be 
passed  three-fourths  of  an  inch  inward  and  a  little  forward 
upon  the  cranial  base ;  this  opening  was  too  small  to  have 
been  made  by  the  bullet.  Three  days  afterward  the  right 
side  of  the  face  became  inflamed,  with  the  occurrence  of 
frontal  headache,  a  more  profuse  sanguinolent  discharge 
from  the  ear,  and  an  elevation  of  temperature  to  102.6°; 
this  was  followed  by  transient  delirium  of  a  low  grade, 
and  by  an  early  subsidence  of  symptoms.  On  the  eighth 
day  the  discharge  from  the  ear  became  foetid  and  the 
patient  somnolent.  An  examination  of  the  ear  by  Dr. 
Callan  disclosed  only  the  discharge  of  pus  from  the  tym- 
panic wound ;  an  examination  of  the  eye  afforded  negative 
results.  After  this  time  a  considerable  swelling  over  the 
ramus  of  the  jaw,  and  a  free  discharge  of  pus  through  the 
tympanum,  were  continued  without  other  symptoms  until 
the  accidental  discharge  of  the  patient  from  the  hospital 
at  the  end  of  a  month.  It  was  learned  that  he  was  appar- 
ently well  for  some  days ;  that  the  discharge  from  the  ear 
then  ceased;  that  he  had  headache,  chills,  and  rapid  dete- 
rioration of  his  general  health ;  and  that  he  died  suddenly 
shortly  afterward. 


CASES    VERIFIED    BY    NECROPSY.  493 


Fractures  Coxfixed  to  the  Craxial  Vertex. 

Case  CXLVII.  Symptoms. — Delirium  on  the  second, 
and  a  convulsion  on  the  fifteenth  day  after  the  original 
injury  alone  noted  and  signifiance  not  recognized.  Late 
symptoms  followed  an  operation  for  fractured  patella  with 
use  of  anaesthetic  six  months  afterward ;  general  convul- 
sions on  the  succeeding  day,  with  Avild  delirium,  and  tem- 
perature of  103°;  the  temperature  and  general  condition 
became  normal  after  tw^enty-four  hours.  One  month  later 
general  convulsions  recurred  after  another  operative  inter- 
ference, and  continued  thirty-six  hours,  preceded  by  tonic 
spasm  of  affected  (left)  limb,  and  succeeded  by  delirium 
and  death  at  the  end  of  nine  hours.  Each  convulsion  was 
preceded  by  restlessness  and  wide  dilatation  of  both 
pupils,  and  in  about  fifteen  seconds  began  in  the  left  face, 
extended  to  the  right  face,  to  the  left  extremities,  and 
finally  became  general.  Temperature  rose  in  twenty-four 
hours  from  101.1°  to  104.8'',  and  afterward  declined  to 
104°. 

Lesions. — Extensive  laceration  of  the  right  temporo- 
sphenoidal  lobe,  three  and  a  half  by  one  and  a  half  inches 
in  its  diameters,  involving  almost  the  whole  of  the 
second  and  third,  and  a  little  of  the  first,  convolutions; 
the  whole  lobe  greatly  atrophied,  indurated,  and  pig- 
mented. Circular  laceration  upon  the  anterior  border  of 
the  right  frontal,  and  another,  an  inch  and  a  half  in 
diameter,  upon  the  inferior  surface  of  the  left  frontal  lobe, 
in  the  second  and  third  orbital  convolutions.  These 
lacerations  were  all  necrotic. 

Case  CXLVIII.  Symptoms. — Hsematoma  and  linear 
fracture  of  left  parietal  region ;  unconsciousness,  which 
was  permanent;  right  facial  paralysis,  and  rigidity  of  both 
arms  and  right  leg;  and  twenty-four  hours  later  paraly- 
sis and  rigidity  of  right  arm ;  paralysis  of  right  leg  prob- 
able.      Temperature    on    admission,    102.6";    pulse,    96; 


494  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

respiration,  36;  later  temperature,  105°.     Death  in  thirty 
hours. 

Lesions. — Epidural  hemorrhage  compressing  laterally 
the  whole  left  cerebrum ;  general  hyperaemia  and  punc- 
tate extravasations. 

Case  CXLIX.  Syniptoms.  —  Consciousness  partially 
lost  and  soon  regained;  vomiting  frequent;  later,  somno- 
lence and  coma.  Temperature  on  admission,  100.2°; 
pulse,  48;  temperature  rose  to  105.4°.  Death  in  twenty- 
seven  hours. 

Lesions. — Compound  comminuted  fracture  of  right 
frontal  bone ;  corresponding  laceration  of  right  Jrontal 
lobe,  through  subcortex  nearly  to  lateral  ventricle,  with 
cortical  hemorrhage  extending  over  parietal  region ; 
slight  pial  hemorrhage  over  left  occipital  lobe ;  minute 
vessels  filled  with  coagula  in  all  parts  of  the  brain. 

Case  CL.  Symptoms.  —  Coma ;  stertor ;  pulse  and 
respiration  slow;  second  day — right  hemiplegia;  eyes 
deviating  to  the  right ;  pupils  normal ;  pulse  feeble  and 
rapid;  respiration  inadequate  from  pulmonary  oedema. 
First  temperature,  some  hours  after  admission,  101.6°; 
second  day,  103.8°  to  105.4°;  third  day,  106.4°,  Death  in 
sixty  hours. 

Lesions. — Laceration  of  left  temporo-sphenoidal  lobe 
extending  into  occipital  region,  with  cortical  hemorrhage 
over  left  motor  area,  and  to  base  of  occipital  lobe ;  general, 
hyperemia  and  thrombosis. 

Case  CLI.  Symptoms. — Unconsciousness  and  irri- 
tability, which  continued  one  week.  Temperature,  99° 
to  100°;  second  and  third  weeks,  delirium  and  con- 
tinued irritability ,  fourth  week,  apathy,  rambling 
speech,  and  delusions,  after  which  patient  was  trans- 
ferred to  another  hospital,  where  he  died  after  opera- 
tion. 

Lesions. — Fracture  in  left  occipito-parietal  region  :  lacer- 
ation of  inferior  surface  of  both  frontal  lobes. 

Case    CLII.      Symptoms. — Shock,      conciousness     re- 


CASES    VERIFIED    BY    NECROPSY.  495 

tained ;  restlessness  and  delirium;  temperature,  100.2°; 
rose  to  104.6°.     Death  on  the  third  day. 

Lesions. — Compound  fracture  of  left  frontal  bone  with 
corresponding  laceration  of  brain  and  meninges ;  general 
hypersemia  and  thrombosis. 

Case  CLIII.  Symptoms. — Unconsciousness;  dilatation 
of  pupils;  rapid  pulse  and  respiration;  temperature,  100°. 
Death  in  four  hours. 

Lesions. — Deep  laceration  of  inferior  surface  of  right 
temporo-sphenoidal,  and  slight  laceration  of  anterior  border 
of  left  temporo-sphenoidal  lobe ;  pial  hemorrhage  over 
superior  surface  of  both  hemispheres. 

Case  CLIV.  Symptoms.  —  Unconsciousness  followed 
by  delirium  soon  after  admission ;  extensive  wounds  of 
the  scalp;  normal  pupils,  right  becoming  dilated  a  little 
later;  temperature,  98.2"";  in  two  hours,  99°;  pulse,  76; 
respiration,  22;  delirium  increased:  pulse  and  respiration 
unchanged.     Death  in  four  hours. 

Lesions. — Compound  doubly  camerated  fracture,  in- 
volving right  parietal  eminence;  skull  very  thick  and 
unsymmictrical ;  posterior  fossae  large,  middle  and  anterior 
fossae  contracted ;  extensive  pial  hemorrhage,  confined  to 
meshes  of  pia,  forming  a  thin  sheet  which  covered  supe- 
rior and  outer  surface  of  right  hemisphere  and  inferior  sur- 
face of  both  occipital  lobes ;  very  marked  general  hyper- 
semia, especially  on  right  side  and  in  pons  and  medulla; 
some  minute  hemorrhages  upon  posterior  border  of  right 
cerebellum  and  upon  the  medulla. 

Case  CLV.  Symptoms.  —  Temporary  unconscious- 
ness; no  other  primary  general  symptom;  temperature 
on  admission,  98.4°;  second  day,  100.6^;  afterward, 
99°+ •  Oil  the  tenth  day,  restlessness  and  slight  deliri- 
um; eleventh  day,  slight  chill  and  increased  delirium, 
which  became  permanent,  but  of  less  active  character; 
fourteenth  day,  post-cervical  rigidity;  and  on  the  fif- 
teenth, slight  general  convulsion ;  mental  condition  slug- 
gish;   pupils    remained    normal;    respiration,    18    to    22: 


496  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

pulse,  104  to  112.  Temperature  on  the  evening  of  the 
tenth  day  rose  to  lOi"  and  on  the  eleventh  day  to  104.6^; 
it  varied  from  that  point  to  103'  till  the  fifteenth  day, 
and  then  rose  progressively  and  reached  107.4°  on  the  six- 
teenth day,  and  death  ensued. 

Lesions. — Compound  fracture  with  slight  depression 
above  right  supra-orbital  ridge,  confined  to  external  table; 
subarachnoid  purulent  effusion  over  both  frontal  lobes  en- 
croaching upon  parietal  and  extending  into  median  fissure. 

Case  CLVI.  Sytnptouis.  —  Unconsciousness,  which 
continued  till  death  at  the  end  of  three  hours;  general 
muscular  rigidity.  Temperature,  101°;  pulse,  98;  respi- 
ration, 20. 

Lesions.  —  Penetrating  wound  and  fracture  of  left  tem- 
poral bone,  above  the  ear,  three-eighths  of  an  inch  in 
diameter,  from  a  blow  inflicted  with  a  revolving  screw- 
driver. The  instrument  passed  through  both  hemi- 
spheres, wounding  the  dura  mater  upon  the  opposite  side, 
and  involving  the  posterior  part  of  the  left  corpus  striatum 
and  both  optic  thalami ;  a  thin  cortical  hemorrhage  covered 
both  hemispheres  and  the  superior  surface  of  the  cere- 
bellum. 

Case  CLVII.  Symptoms.  —  Patient,  nine  days  pre- 
vious to  admission,  came  home  with  head  bleeding,  ver- 
tigo, nausea,  and  feeling  of  weakness,  from  an  injury  of 
unknown  origin,  and  was  said  to  have  been  afterward 
treated  for  pneumonia.  On  admission,  he  was  found  to 
have  compound  depressed  fracture  of  right  parietal  bone, 
and  the  wound  was  foul  and  suppurating;  mental  condi- 
tion stupid ;  left  hemiplegia  and  right  facial  paralysis ;  de- 
viation of  tongue  to  the  left :  opposite  radial  puLsations 
symmetrial;  .slight  dilatation  of  left  pupil;  coma  super- 
vened an  hour  later,  and  convuLsive  movements  of  the 
right  face  four  hours  and  a  half  after  admission.  After 
elevation  of  the  depressed  bone,  and  escape  of  a  small 
amount  of  pus  from  below  the  dura  mater,  the  pupils 
became  normal,  and  there  was  a  single  clonic  convulsion 


CASES    VERIFIED    BY    NECROPSY.  497 

of  the  left  side.  Death  occurred  thirteen  hours  and  a  half 
from  time  of  admission.  Temperature  for  twelve  hours 
was  io6°-|-,  and  afterward  107.2°;  one  hour  post  mortem, 
107.4°.     Pulse,  118,  170,  158;  respiration,  44  to  60. 

Lesions. — Compound  depressed  fracture  of  right  parietal 
bone,  just  behind  coronal  suture,  and  half  an  inch  from 
median  line ;  purulent  subarachnoid  effusion  over  convex 
surface  of  right  hemisphere,  which  anteriorly  extended 
to  base;  superficial  laceration  of  right  parietal  lobe  be- 
neath site  of  fracture,  which  was  prolonged  subcorti- 
cally,  both  anteriorly  and  posteriorly,  but  did  not  reach 
motor  area;  pus  from  this  laceration  had  escaped  in 
small  quantity  into  arachnoid  cavity;  left  hemisphere 
markedly  hypersemic  and  moderately  oedematous. 

Case  CLVIII,  Symptoms.' — Consciousness  primarily 
retained ;  thirty  minutes  later  general  convulsions  followed 
by  complete  unconsciousness  and  an  apparently  moribund 
condition.  Elevation  of  a  depressed  portion  of  the  left 
parietal  bone  restored  consciousness  and  some  strength  to 
the  circulation.  Convulsions  recurred  next  day,  and  death 
ensued  in  twenty-three  hours.  Temperature,  102.4°  to 
104.4°;  pulse,  108  to  160;  respiration,  32  to  60. 

Lesions. — Fracture  confined  to  vertex;  epidural  hemor- 
rhage of  small  extent,  and  laceration  of  inferior  surface 
of  right  frontal  and  temporo-sphenoidal  lobes.  (Infant, 
aged  twenty-two  months.) 

Case  CLIX.  Symptoms. — Patient  admitted  to  the  hos- 
pital semi-conscious,  and  without  evident  external  injury; 
both  arms  rigid  and  extended ;  spasmodic  movements  of 
arms  and  feet;  reflexes  abolished.  Pulse  and  respiration 
full  and  slow.  Temperature,  99.8°.  Pupils  slightly  di- 
lated.    Death  in  twelve  hours. 

Lesions. — Fracture  of  right  temporal  bone  above  the 
ear,  laceration  of  the  dura  mater,  and  epidural  hemor- 
rhage. 

Case  CLX.  Symptoms. — Consciousness  entirely  lost, 
partially  regained,  and  again  entirely  lost  in  the  ambu- 
32 


498  INJURIES   OF    THE    BRAIN    AND    MEMBRANES, 

lance,  and  not  regained;  pupils  contracted,  skin  cold  and 
moist;  hemorrhage  from  both  nostrils;  large  haematoma  in 
right  fronto-parietal  region,  and  linear  fracture  discovered 
by  incision ;  loss  of  urinary  control,  and  vomiting.  Some 
hours  later  the  right  pupil  was  more  contracted  than  the 
left,  there  were  muscular  twitchings,  and  there  was  slight 
delirium.  Second  day:  right  radial  pulsations  were  much 
fuller  and  stronger  than  the  left ;  great  difficulty  in  deglu- 
tition. Third  day:  unconsciousness  was  more  profound 
and  the  left  pupil  slightly  dilated ;  the  right  was  still  con- 
tracted. Death  occurred  in  two  and  one-half  days.  Tem- 
perature on  the  first  day  was  99°  to  100.6°;  on  the  second 
day,  100°  to  100.6°;  on  the  third  day,  100°  to  105.8°,  and 
receded  post  mortem.  Pulse,  60  to  90,  and  on  the  third 
day,  70  to  120.     Respiration,  36,  28,  66. 

Lesions. — Haematoma  over  whole  vertex;  separation  of 
coronal  suture,  and  fissure  in  right  parietal  bone  extend- 
ing from  it,  which  was  discovered  during  life;  large  epi- 
dural clot  over  left  parietal  region,  and  another  over  right 
frontal  region,  both  very  black  and  friable ;  superior  longi- 
tudinal sinus  filled  with  very  black  firm  clot;  epidural  clot 
in  left  middle  fossa;  rupture  of  longitudinal  sinus;  large 
pial  hemorrhage  over  left  frontal,  temporal,  and  parietal 
lobes;  no  laceration  of  any  part  of  brain  substance;  brain 
exceedingly  hypersemic  and  oedematous;  moderate  serous 
effusion  in  lateral  ventricles. 

Case  CLXI.  Symptoms. — Unconsciousness  lasting  for 
a  few  moments;  on  admission  to  hospital,  pupils  and 
mental  condition  normal,  contusion  of  scalp  in  occipito- 
parietal region,  and  vomiting.  Temperature,  98.6°; 
pulse,  60;  respiration,  15.  Muscular  twitchings  of  face, 
arms,  and  legs,  which  were  of  brief  continuance.  Two 
hours  later  irritability  followed  by  delirium,  and  soon 
after  by  coma,  which  continued  till  death.  Twelve  hours 
later  still,  vomiting,  loss  of  urinary  control.  Tempera- 
ture, 101.4°;  pulse,  74;  and  respiration,  20.  Temperature 
rose  progressively  to   104°,   and  respiration  to  42,  at  the 


CASES   VERIFIED    BY   NECROPSY.  499 

time  of  death  in  thirty-two  hours.  Loss  of  urinary  control 
continued  and  bowels  were  not  moved.  The  muscular 
twitchings  recurred  and  the  respiration  became  of  the 
Cheyne-Stokes  variety.  Temperature  one  hour  post  mor- 
tem was  104.2°. 

Lesions. — Linear  fracture  extending-  from  the  right 
parieto-occipital  junction  through  the  right  squamous  por- 
tion of  the  temporal  bone ;  cortical  hemorrhage  covering 
the  right  hemisphere  and  a  portion  of  the  left,  and  at  the 
base  both  lobes  of  the  cerebellum  and  the  pons  ;  laceration, 
one-half  inch  deep  and  one-fourth  inch  wide,  extending 
from  a  point  in  the  parietal  lobe  corresponding  to  the 
origin  of  the  fracture  to  the  middle  of  the  first  right 
temporal  convolution ;  no  marked  general  cerebral  hyper- 
semia. 

Case  CLXII.  Symptonis. — Transient  unconsciousness. 
On  admission  to  the  hospital,  compound  depressed  fracture 
of  right  frontal  bone ;  vomiting ;  depressed  fragments 
elevated,  and  open  fissure  discovered  running  into  occipi- 
tal bone;  mental  condition  normal  after  recovery  from 
ether.  Second  day :  slight  delirium,  restlessness,  followed 
by  heaviness,  somnolence,  and  loss  of  urinary  control. 
Third  day:  restlessness,  delirium,  and  stupor.  Death 
occurred  in  fifty  hours.  The  temperature  on  admission 
was  99°,  and  was  little  changed  during  the  first  day;  on 
the  second  day  it  was  102°,  101°,  102.6°;  and  on  the  third 
day,  103°,  102.2°,  105.5°,  with  immediate  post-mortem  re- 
cession. The  pulse  was  98,  112,  93;  the  respiration  was 
20,  38,  28. 

Lesions. — Open  fissure  extending  from  depression  in 
the  posterior  part  of  right  frontal  bone  into  right  su- 
perior occipital  fossa;  epidural  hemorrhage  over  right 
hemisphere,  very  thick  and  firm  upon  its  lateral  aspect, 
originating  from  the  diploic  vessels ;  no  other  hemorrhage ; 
cortical  contusion  of  right  parietal  lobe  near  its  lateral 
border,  and  another  upon  inferior  surface  of  left  tem- 
poral   lobe;    excessive    general    hyperasmia    and    oedema 


500  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

of  brain,  and  a  small  amount  of  clear  serum  in  lateral 
ventricles. 

Case  CLXIII.  Symptoms. — Patient  fell  upon  the  side- 
walk ;  profound  unconsciousness ;  wound  in  left  parietal 
region;  surface  pallid,  cool,  and  moist;  pupils  slightly 
dilated;  respiration  labored;  left  radial  pulsations  fuller 
and  stronger  than  the  right ;  no  fracture  discovered.  Con- 
sciousness was  sufficiently  restored  after  admission  to 
hospital  to  permit  answer  to  simple  questions,  and  in 
fifteen  minutes  was  again  lost;  head  and  eyes  turned  to 
the  right;  slight  twitching  of  the  right  fingers;  hemor- 
rhage from  the  left  nostril.  Temperature,  102.8°;  pulse, 
80;  respiration,  32.  Loss  of  urinary  and  faecal  control. 
Consciousness  was  not  again  restored ;  right  pupil  became 
widely  dilated  and  irresponsive  to  light,  and  the  left  con- 
tracted; lower  left  facial  paralysis  was  developed,  and  at 
times  there  was  Cheyne-Stokes  respiration;  the  right 
radial  pulse  became  almost  imperceptible,  while  the  left 
remained  full  and  strong.  Death  occurred  in  forty-eight 
hours.  Temperature  varied  from  100.8°  to  102.2°;  pulse, 
128  to  130;  respiration,  30  to  28. 

Lesions. — Separation  of  left  coronal  suture  for  one  and 
one-half  inches,  and  interval  filled  with  clot;  slight  epi- 
dural hemorrhage  at  that  point,  and  slight  pial  hemor- 
rhage over  left  fissure  of  Rolando;  extensive  laceration  of 
right  temporal  lobe  involving  nearly  its  whole  lateral  sur- 
face; consequent  cortical  hemorrhage,  which  extended 
through  a  wound  of  the  dura  mater  and  covered  the  region 
of  the  right  hemisphere. 

Case  CLXIV.  Symptoms.  —  Primary  and  permanent 
unconsciousness.  On  admission  to  the  hospital,  right 
hemiplegia ;  all  reflexes  exaggerated ;  loss  of  urinary  and 
faecal  control;  right  pupil  dilated,  left  normal,  and  both 
irresponsive  to  light;  large  hasmatoma  in  parieto-occipital 
region;  pulse  full  and  very  irregular,  and  right  radial 
pulsations  fuller  and  stronger  than  the  left.  Death  oc- 
curred two  hours  later.     Temperature  on  admission,  98°, 


CASES   VERIFIED    BY   NECROPSY.  501 

receded  to  95.6°,  and  then  rose  progressively  to  104.8°. 
Pulse,  56,  ^6,  54,  128.  Respiration,  4,  18,  12,  24,  14,  22, 
18,  26,  12. 

Lesions. — Linear  fracture  across  posterior  part  of  both 
parietal  bones  from  one  squamous  portion  to  the  other. 
Thick  cortical  clot  covering  left  parietal  lobe,  in  greatest 
amount  over  external  part  of  superior  surface,  and  extend- 
ing to  frontal  and  to  occipital  lobes  from  a  laceration 
which  excavated  and  filled  with  clot  the  entire  parietal 
lobe.  An  independent  subcortical  laceration  in  the  left 
frontal  lobe  was  one  and  one-half  inches  in  diameter.  A 
moderate  cortical  hemorrhage  on  the  right  side  was  de- 
rived from  a  laceration  of  the  right  parietal  lobe,  which 
was  linear  in  the  cortex,  and  subcortically  was  three- 
fourths  of  an  inch  wide  by  one  and  one-half  inches  in 
depth.  There  was  slight  cortical  hemorrhage  in  the  left 
middle  fossa  and  upon  the  superior  surface  of  the  cerebel- 
lum ;  slight  hyperasmia  and  no  oedema  of  the  brain  sub- 
stance. There  was  no  lesion  of  the  pons  or  medulla,  and 
no  hemorrhage  upon  their  surfaces. 

Case  CLXV.  Symptoms.  —  Patient  fell  fifteen  feet, 
striking  upon  his  head;  primary  and  permanent  uncon- 
sciousness; stertor;  pupils  normal;  no  hemorrhage,  or 
loss  of  f secal  or  urinary  control ;  vomiting ;  all  reflexes  ex- 
aggerated; restlessness,  which  soon  required  mechanical 
restraint;  hsematoma  in  left  parietal  region.  Death  in 
thirteen  hours.  Temperature  on  admission  to  the  hospi- 
tal, 99.4°,  rising  progressively  with  one  recession  of  0.4°, 
to  105.2°,  and  post-mortem  elevation  to  107.4°.  Pulse,  88 
to  116;  respiration,  22  to  38. 

Lesions. — Linear  fracture  of  left  parietal  bone,  four 
inches  in  length,  parallel  to  the  temporal  ridge;  extensive 
laceration  of  left  temporal  and  parietal  lobes,  extending 
into  the  posterior  cornu  of  the  lateral  ventricle,  with  large 
cortical  hemorrhage  upon  their  surfaces ;  laceration  of  in- 
ferior surface  of  right  frontal  lobe,  with  small  cortical 
hemorrhage. 


502  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

Case  CLXVI.  Symptoms. — Patient  found  unconscious 
after  having  fallen  twenty-five  feet  six  hours  previously ; 
on  admission  to  hospital,  skin  cold  and  wet  from  ex- 
posure to  the  rain;  compound  depressed  fracture  in  right 
temporal  region,  with  fissure  running  across  coronal  su- 
ture; small  depressed  fragment  elevated  and  removed 
from  parietal  bone;  right  pupil  widely  dilated  and  im- 
movable ;  muscular  rigidity  of  left  side,  which  disappeared 
after  elevation  of  osseous  fragment;  compound  fracture 
of  left  forearm.  Ten  hours  later  there  were  some  transient 
manifestations  of  consciousness ;  urinary  control  was  lost. 
On  the  second  day,  left  unilateral  convulsions  occurred 
every  fifteen  minutes  during  two  hours,  and  two  similar 
paroxysms  on  the  third  day;  rigidity  of  the  left  arm  and 
leg  was  permanent  after  the  first  convulsion.  Anaesthesia 
was  indeterminate.  Temperature  was  irregular;  it  was 
100.2°  on  admission,  rose  to  103°  in  six  hours,  fell  to 
100.6°  in  twenty-eight  hours  following,  then  rose  pro- 
gressively to  107°  in  twenty-one  hours  more,  when  it  was 
reduced  by  alcohol  bath  to  102.8";  it  then  again  rose  pro- 
gressively to  106.4°,  at  death  at  the  end  of  sixty-eight 
hours.     Pulse,  84  to  152;  respiration,  24,  40,  28,  52. 

Lesions. — Small  epidural  hemorrhage  over  left  occipital 
lobe  and  external  border  of  left  cerebellar  lobe ;  moderate 
general  hyperaemia  and  oedema  of  the  brain ;  well  marked 
contusion  of  inner  surface  of  left  optic  thalamus  anteriorly, 
and  deep  and  wide  laceration  of  the  superior  and  inner 
surfaces  of  the  right  optic  thalamus ;  contusion  of  fornix 
anteriorly  with  very  distinct  punctate  extravasations ;  clot 
one-half  inch  in  diameter  in  the  centre  of  the  left  cere- 
bellar lobe. 


CASES   VERIFIED    BY    NECROPSY.  '  503 


Fractures  Confined  to  the  Cranial  Vertex  from 
Pistol-Shot  Wound. 

Case  CLXVII.  ■  Symptoms. — Coma;  stertor;  rapid 
pulse.     Temperature  fell  to  95°.     Death  in  four  hours. 

Lesions. — Pistol-shot  fracture  of  right  frontal  bone  : 
ball  entered  anterior  extremity  of  fissure  of  Sylvius,  trav- 
ersed right  frontal  lobe  just  below  cortex,  parallel  to  its 
curve  and  a  little  backward,  crossed  median  fissure  into 
left  parietal  lobe,  impinged  upon  left  parietal  bone,  which 
it  fractured,  and  fell  back  into  its  track  half  an  inch  below 
the  surface,  where  it  rested ;  little  intracranial  hemorrhage. 

Case  CLXVIII.  Symptoms. — Coma,  soon  becoming 
profound;  normal  pupils;  general  muscular  twitching. 
Death  in  twelve  hours. 

Lesions. — Pistol-shot  fracture  of  right  frontal  bone; 
ball  traversed  right  hemisphere  nearly  in  its  antero- 
posterior diameter,  just  above  corpus  callosum,  impinged 
upon  inner  surface  of  occipital  bone,  and  fell  into  inferior 
occipital  fossa  above  dura  mater ;  considerable  cortical  hem- 
orrhage. 

Case  CLXIX.  Symptoms. — Pistol-shot  wound  of  right 
temporal  region;  unconsciousness;  no  other  immediate 
general  symptom;  pulse,  70;  temperature,  99°;  con- 
sciousness soon  restored;  mental  processes  normal  but 
sluggish ;  some  discharge  of  brain  matter  followed  an  un- 
successful attempt  to  locate  and  remove  the  ball  on  the 
second  day;  wound  afterward  practically  healed;  mental 
condition  apathetic,  rational,  but  without  any  manifesta- 
tion of  interest  in  surrounding  persons,  things,  or  circum- 
stances ;  urine  and  f^ces  voided  without  any  indication  of 
consciousness.  Temperature,  loo'-l-  to  103.6°,  usuall}' 
101°+.      Death  in  thirty  days. 

Lesions. — Pistol-shot  fracture  of  right  frontal  bone; 
ball  entered  middle  of  right  third  frontal  convolution, 
passed  through  central  portion  of  both  frontal  lobes  to  a 


504  INJURIES    OF    THE    BRAIN   AND    MEMBRANES. 

jDoint  just  behind  ascending  arm  of  fissure  of  Sylvius  in 
upper  portion  of  island  of  Reil,  and  rested  in  a  cavity  five- 
eigbths  by  seven-eighths  of  an  inch  in  its  diameters,  sur- 
rounded by  clot  and  brain  detritus. 

Case  CLXX.  Symptoms. — Pistol-shot  wound  of  right 
side  of  the  head.  Left  facial  paralysis  on  second  day ;  her- 
nia cerebri  on  the  third  day ;  mental  condition  deteriorated 
and  paralysis  increased.  Patient  transferred  to  Bellevue 
Hospital  on  the  thirtieth  day;  then  suffering  from  hys- 
teria and  melancholia,  which  had  preceded  the  infliction  of 
the  injury;  restlessness;  loss  of  control  of  urine  and 
faeces;  left  hemiplegia;  slight  dilatation  of  pupils;  articu- 
lation difficult;  sensation  normal;  pain  in  right  supra- 
orbital region  and  at  seat  of  the  wound ;  mental  processes 
slow.  Temperature,  ioo°;  pulse,  120  to  140;  respiration, 
20.  At  site  of  injury  there  was  an  infected  granulating 
wound  through  which  a  probe  could  be  passed  into  the 
brain.  Four  days  later,  under  ether,  an  attempt  was  made 
to  locate  the  ball,  and  a  cavity  was  found  to  exist,  extend- 
ing nearly  transversely  inward  two  inches  and  a  half,  with 
moderately  firm  and  well-defined  w^all,  and  having  a  small 
bit  of  bone  at  the  bottom.  The  ball  was  not  discovered. 
Temperature  from  admission  had  risen  to  102.6°  at  time 
of  exploration.  Death  occurred  two  days  later;  tempera- 
ture then,  107.4°. 

Lesions. — Pistol-shot  fracture  of  right  temporal  bone  in 
squamous  portion;  osseous  w^ound  had  been  enlarged  by 
trephination  ;  slight  hemorrhage  over  right  occipital  lobe 
and  a  few  threads  of  yellow  exudate  in  same  region  and 
on  the  right  side  of  the  median  fissure ;  ball  passed 
through  lower  face  area,  nearly  transversely  inward  to  a 
point  beneath  the  median  surface  and  just  above  the  cal- 
loso-marginal  fissure;  was  then  deflected  backward  at  a 
right  angle  by  the  resistance  of  the  falx  cerebri,  and  was 
lodged  an  inch  behind  the  cavity  recognized  at  the  time  of 
exploration.     General  cerebral  hyerasmia. 

Case  CLXXI.     Symptoms. — Pistol-shot  wound  of    left 


CASES   VERIFIED    BY   NECROPSY.  505 

side  of  the  head:  unconsciousness,  which  continued  till 
death,  five  hours  later;  slight  dilatation  of  left  pupil. 
Temperature  one  hour  after  reception  of  injury,  98.2° ;  two 
hours  afterward,  97.6°;  fifteen  minutes  before  death,  99°. 
Pulse,  118  to  132;  respiration,  28;  later,  32  and  stertorous; 
fifteen  minutes  before  death,  7;  and  finally,  2. 

Lesions. — Pistol-shot  fracture  of  squamous  portion  of 
left  temporal  bone  in  its  posterior  portion,  an  inch  below 
temporal  ridge:  foyer  of  entrance  triangular;  each  arm 
half  an  inch  in  length;  bone  comminuted,  and  the  frag- 
ments penetrated  the  cerebral  cortex.  Ball  entered  tem- 
poral lobe  between  two  large  branches  of  the  meningeal 
artery,  passed  transversely  across  the  brain  immediately 
below  the  cortex,  and  was  lodged  in  the  right  parietal 
lobe ;  cortical  hemorrhage  from  injury  of  the  right  parietal 
lobe  by  the  ball  in  its  course  extended  under  the  tento- 
rium and  over  the  pons  and  medulla,  and  was  apparently 
the  immediate  cause  of  death;  cerebral  hyperaemia  con- 
fined to  the  vicinage  of  the  bullet  track. 

Case  CLXXII.  Symptoms.  ■ —  Suicidal  pistol  -  shot 
wound.  Primary  and  permanent  unconsciousness;  loss  of 
urinary  and  fsecal  control.  Death  in  seventeen  hours. 
Temperature  one  hour  after  reception  of  injury,  98.6°, 
rising  progressively  to  105.4°;  pulse,  44  to  116;  respira- 
tion, 28  to  34. 

Lesions. — Ball  of  38  cal.  entered  one  and  one-half  inches 
behind  right  external  angular  process.  External  wound 
circular,  patulous,  and  smaller  than  the  ball.  Skin  said 
to  have  been  smoked  but  no  trace  remaining ;  hair  singed, 
but  skin  not  scorched  or  burnt;  right  eye  ecchymotic; 
grains  of  powder  closely  embedded  in  the  skin  over  an 
area  of  four  by  three  inches,  some  hundreds  in  number, 
and  confined  to  the  temporal  region.  Subcutaneous 
tissues  not  blackened ;  much  hemorrhage  into  the  scalp 
from  wound  of  entrance  and  of  exit.  The  ball  passed 
through  right  temporal  muscle  and  through  both  frontal 
lobes,  and  was  lodged  in  the  osseous  wound  of  exit  nearly 


506  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

opposite  its  entrance,  lying  upon  its  long  axis.  The 
osseous  entrance  was  irregular  in  form,  larger  than  the 
ball,  and  neither  comminuted  nor  fissured;  the  exit  was 
comminuted  in  an  area  one  inch  in  diameter.  The  skull 
was  thin.  The  ball  severed  the  middle  meningeal  artery, 
but  there  was  no  epidural  hemorrhage.  Thick  arachnoid 
clots  covered  both  frontal  and  the  right  parietal  lobes,  and 
extended  into  the  median  fissure  upon  the  right  side  of 
the  falx  cerebri,  and  occupied  all  the  basic  fossae.  Both 
frontal  lobes  were  extensively  excavated  and  filled  with 
clot,  and  some  fluid  blood  was  found  in  the  left  lateral 
ventricle. 

Case  CLXXIII.  Symptoms. — Subject  found  dead  with 
pistol  in  his  hand  a  moment  after  suicidal  shot  was  heard. 

Lesions. — Ball  entered  tv\'o  and  three-fourths  inches 
above  the  right  ear;  wound  smaller  than  the  ball,  circular, 
and  inverted;  no  smoke  stain,  or  grains  of  powder  dis- 
cernible; brain  matter  in  the  hair;  skin  burned  on  the 
posterior  aspect  of  the  wound,  and  hair  slightly  singed; 
subcutaneous  tissues  blackened;  right  temporal  muscle 
and  scalp  on  right  side  infiltrated  with  blood.  Os- 
seous entrance  large,  irregular,  and  not  comminuted 
or  fissured ;  no  powder  appreciably  carried  into  the  cra- 
nial cavity.  The  ball,  of  0.32  cal.,  passed  through  the 
groove  for  the  middle  meningeal  artery,  which  was 
abnormally  broad  and  deep,  entered  the  brain  at  the  pos- 
terior border  of  the  right  frontal  lobe,  just  in  front  of  the 
fissure  of  Sylvius,  passed  out  of  its  anterior  border,  crossed 
the  inferior  median  fissure,  re-entered  the  brain  through 
the  inner  margin  of  the  left  frontal  lobe,  traversed  the 
left  lateral  ventricle,  leaving  a  small  fragment  embedded  in 
the  surface  of  the  caudate  nucleus  without  other  injury, 
and  was  lodged  in  the  posterior  part  of  the  left  temporal 
lobe ;  small  fragments  of  bone  were  found  along  its  track 
and  one  was  driven  beyond  the  ball  and  embedded  in  the 
posterior  part  of  the  right  parietal  lobe.  The  brain  was 
generally  hyperaemic.     The  surface  of  both  hemispheres 


CASES   VERIFIED    BY   NECROPSY.  $0/ 

was  covered  with  blood,  and  a  great  quantity  had  escaped 
from  the  external  wound.  The  subarachnoid  spaces  at 
the  vertex  contained  much  serous  fluid  and  the  arachnoid 
membrane  was  opaque.  The  surface  of  the  right  optic 
thalamus  was  softened,  and  of  a  greenish  color  and  watery 
appearance.  The  right  lateral  ventricle  communicated 
with  a  small  cavity  in  the  parietal  lobe,  which  in  its  wall 
was  of  the  same  character  as  the  thalamic  surface.  This 
substance,  examined  later,  was  found  to  consist  of  a  net- 
work of  fine  neuroglia  without  cells  and  with  only  a  few 
capillaries.  The  patient  was  ascertained  to  have  had  a 
cerebral  hemorrhage  four  years  previously,  and  to  have 
since  suffered  from  mental  impairment. 

Case  CLXXIV.  Symptoms.  —  Patient  found  uncon- 
scious with  pistol-shot  wound  two  inches  behind  right 
external  angular  process ;  pulse  and  respiration  slow;  un- 
consciousness not  profound ;  twitchings  of  lower  ex- 
tremities; hemorrhage  free,  and  pupils  both  moderately 
dilated.  After  admission  to  hospital,  no  symptoms  noted 
except  continued  unconsciousness  and  loss  of  faecal  con- 
trol. The  wound  was  triangular,  one-half  inch  in  length 
upon  each  border,  edges  burned,  and  muscle  exposed  and 
blackened ;  brain  matter  upon  the  surface ;  powder  was 
ingrained  over  lower  part  of  the  ear,  ramus  of  the  jaw, 
posterior  cervical  triangle,  and  also  in  the  submaxillary 
region.  The  extreme  measurements  of  this  space  were 
31^"  and  4";  no  grains  were  embedded  nearer  the  wound. 
The  osseous  entrance  was  large  and  the  bone  depressed ; 
the  exit  was  large  and  comminuted.     Death  in  two  hours. 

Lesions. — Ball  entered  the  brain  just  above  the  right 
fissure  of  Sylvius  anteriorly,  passed  upward,  inward,  and 
a  little  backward,  through  the  falx  cerebri,  re-entered  the 
brain  through  the  median  surface  of  the  left  parietal  lobe, 
and  made  exit  just  behind  the  Rolandic  fissure.  Many 
minute  fragments  of  bone  and  scattered  grains  of  powder 
were  discovered  in  the  track  of  the  ball.  The  right  hemi- 
sphere was  moderately  hypersemic,  and  the  left  very  hy- 


508  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

peraemic  and  oedematous.  There  was  considerable  corti- 
cal hemorrhage  in  left  middle  and  posterior  basic  fossae 
and  over  left  vertex,  and  a  large  hemorrhage  of  intra- 
cranial origin  existed  in  the  scalp  over  both  parietal  and 
both  occipital  regions.  The  osseous  exit  of  the  ball, 
which  was  of  0.38  cal.,  was  through  the  left  parietal  bone 
a  little  behind  its  middle  portion  and  near  the  median 
line. 

Case  CLXXV.  Symptouis. — Patient  fell  while  in  an 
epileptic  convulsion,  and  was  admitted  to  the  hospital  in 
an  unconscious  condition,  with  twitching  of  the  right  side, 
frothing  at  the  mouth,  and  a  large  scalp  wound  of  the  back 
of  the  head ;  and  remained  unconscious  till  his  death  six- 
teen days  afterward. 

Lesions. — Two  cranial  openings  made  by  trephination 
previous  to  present  injury.  Lacerations  of  left  temporal 
lobe  involving  anterior  extremity  of  first  and  second  con- 
volutions, and  middle  portion  of  the  first,  all  in  process  of 
repair,  with  clean  surfaces  and  rounded  edges. 

This  man  was  shot  in  1881,  fourteen  years  previous  to 
his  death,  the  ball  entering  the  cranial  cavity  just  behind 
and  below  the  left  external  angular  process.  Epilepsy 
followed,  and  several  months  before  his  death  he  was 
trephined  and  fragments  of  bone  were  removed  from  near 
the  wound  of  entrance.  He  was  again  trephined,  then  in 
the  occipital  region,  within  the  month  of  his  admission  to 
the  hospital.  At  necropsy,  a  ball  of  0.22  cal.  was  found 
lodged  in  the  left  trunk  area,  near  the  median  fissure, 
projecting  through  the  cortex.  A  canal,  lined  with  a 
bloodstained  membrane,  and  situated  between  the  ascend- 
ing frontal  and  first  parietal  convolutions,  led  from  the 
point  of  entrance  nearly  to  the  site  of  the  ball.  A  fungus 
cerebri  protruded  from  the  occipital  opening  of  tre- 
phination. 

The  membranous  canal  was  apparently  formed  after 
the  primary  operation. 

Case  CLXXVI.— Subject  found  dead. 


CASES    VERIFIED    BY    NECROPSY.  509 

Lesioiis. — The  face  had  been  cleansed  and  there  were 
consequently  no  blood,  smoke  stain,  or  free  grains  of  un- 
burned  powder.  The  external  wound,  which  was  situated 
seven-eighths  of  an  inch  internal  to  the  right  external 
angular  process,  was  linear,  one  and  one-half  inches  in 
length,  and  its  edge  was  burned  in  the  central  portion; 
there  was  no  other  burn  and  there  were  no  grains  of 
powder  embedded  in  the  skin.  The  temporal  muscle  was 
lacerated  and  blackened  in  an  area  of  one  inch  in 
diameter  and  the  layers  of  the  scalp  were  infiltrated  with 
blood  in  both  fronto-parietal  regions.  The  osseous 
entrance  was  one-half  inch  above  the  right  supra-orbital 
ridge,  with  a  fissure  extending  across  the  frontal  bone  into 
the  left  squamous  region,  but  was  not  comminuted.  The 
ball  passed  through  the  anterior  part  of  both  frontal  lobes, 
lacerating  their  inferior  surfaces,  and  fell  back  into  its  track 
without  penetrating  the  opposite  dural  surface  ;  it  was  then 
deflected  posteriorly,  and  was  lodged  deep  in  the  cerebrum 
about  the  right  parieto-occipital  junction.  The  ball  track 
was  filled  with  clot  and  contained  a  fragment  of  bone  in 
each  frontal  lobe ;  no  powder  grains  were  appreciable. 
The  ball  was  of  0.22  cal.  Abundant  cortical  hemorrhage 
and  moderate  general  hyperaemia. 

Case  CLXXVII.— Subject  found  dead. 

Lesions. — External  wound,  three-sixteenths  of  an  inch  in 
diameter,  with  edge  burned  and  inverted,  was  situated  two 
inches  behind  and  one-fourth  of  an  inch  below  right  ex- 
ternal angular  process ;  free  external  hemorrhage  :  smudge 
of  smoke  upon  the  lobe  of  the  right  ear;  no  unburned 
grains  upon  the  surface  or  embedded  in  the  skin ;  hair 
burned  over  an  area  one-half  inch  in  diameter;  subcutane- 
ous hemorrhage  above  occipito-frontalis  muscle,  which  was 
scorched  over  an  area  of  one-half  inch.  The  osseous  en- 
trance was  one-half  inch  long  and  OYal,  and  the  eroded  sur- 
face of  the  internal  table  was  powder  stained ;  no  Assuring 
or  comminution.  The  ball  of  0.32  cal.  passed  through  the 
anterior  extremity  of  the  fissure  of  S^dvius,  and  downward 


510  INJURIES   OF   THE   BRAIN    AND    MEMBRANES. 

and  forward  to  the  median  line,  where  its  track  was  lost;  it 
was  probably  deflected  by  striking  upon  the  cranial  base, 
though  the  dura  mater  was  uninjured,  and  it  was  subse- 
quently found  in  the  left  centrum  ovale  in  a  direction  up- 
ward and  backward  from  its  original  course;  it  was 
slightly  turned  from  its  vertical  axis,  and  lying  in  a  track 
scarcel}^  larger  than  itself.  There  were  free  cortical 
hemorrhage  and  marked  but  not  excessive  cerebral 
hypersemia. 

Case  CLXXVIII.— Death  immediate. 

Lesions. — External  wound  circular,  one-eighth  of  an 
inch  in  diameter,  and  situated  one  and  one-half  inches  be- 
hind, and  three-fourths  of  an  inch  above,  the  external 
angular  process;  a  few  loose  powder  grains  in  the  hair; 
burned  area,  one-half  inch  in  diameter,  black  and  crisp, 
moderate  external  hemorrhage :  pupils  unsymmetrically 
dilated;  subcutaneous  burned  area  of  three-fourths  of  an 
inch  above  the  temporal  fascia;  temporal  muscle  infil- 
trated with  blood.  The  osseous  entrance  was  below  the 
temporal  ridge,  quadrilateral,  clean  cut,  and  three-eighths 
of  an  inch  in  its  diameter.  The  ball  of  0.32  cal.  en- 
tered the  frontal  lobe,  furrowed  its  base,  and,  passing 
obliquely  inward  and  backward,  perforated  the  left 
temporal  lobe  between  the  first  and  second  convolutions, 
penetrated  the  dura  mater,  fractured  the  squamous  portion 
of  the  temporal  bone,  slightly  elevating  and  fissuring  the 
external  table,  and  fell  back  into  the  cerebral  cortex. 
Cortical  hemorrhage  was  confined  to  the  furrow  upon  the 
basal  surface,  and  to  the  anterior  surface  of  the  pons  and 
medulla,  extending  into  the  spinal  canal. 

Case  CLXXIX.— Subject  found  dead. 

Lesions. — Free  hemorrhage  from  mouth  and  nostrils; 
pupils  symmetrically  dilated.  External  wound  one  and 
one-fourth  inches  behind,  and  one-half  inch  above, 
right  external  angular  process;  smoke  stain  in  front  of 
ear;  some  grains  of  powder  on  the  surface  in  front  of 
wound;    black  area   of   one   inch    in    diameter  over  tem- 


CASES   VERIFIED    BY   NECROPSY.  511 

poral  fascia;  powder  stain  in  temporal  muscle.  The 
osseous  entrance  was  three-eighths  of  an  inch  in  diameter, 
in  the  upper  part  of  the  temporal  fossa ;  and  a  fissure  ex- 
tended posteriorly  around  the  calvarium  into  the  opposite 
temporal  fossa.  The  contiguous  surfaces  of  the  bone  and 
dura  mater  were  powder  stained  over  an  area  of  one  inch. 
The  ball,  of  0.32  cal.,  traversed  both  frontal  lobes,  in 
front  of  and  a  little  above  the  anterior  border  of  the  corpus 
callosum,  wounded  the  dura  mater,  and  finely  fissured  the 
external  table  of  the  left  parietal  bone  near  its  eminence, 
without  injury  to  the  internal  table;  it  then  passed  back- 
ward between  the  dura  mater  and  the  cerebral  surface, 
and  lodged  in  a  sulcus  between  two  convolutions  upon  the 
inferior  surface  of  the  occipital  lobe.  It  was  discovered 
only  on  section  of  the  brain. 

Case  CLXXX.  Symptoms. — Suicide.  Bullet  of  0.32 
cal.  entered  right  temporal  region  two  and  three- 
eighths  inches  behind  external  angular  process  and  one 
and  three-eighths  inches  above  it ;  diameter  of  wound,  one- 
eighth  of  an  inch ;  margin  burned,  one-sixteenth  inch  ;  skin 
burned  in  a  triangular  area  below  the  wound,  one  and 
one-fourth  inches  long,  and  one  inch  wide  at  its  base 
above ;  unburned  grains  of  powder  which  were  partly  em- 
bedded in  this  space  were  removed  by  the  hemorrhage 
and  by  ablution.  Complete  unconsciousness,  stertor, 
moderately  contracted  pupils,  and  free  hemorrhage  from 
the  wound ;  no  muscular  symptoms.  Temperature  on  ad- 
mission to  the  hospital  two  or  more  hours  after  injury, 
98";  pulse  62.  Thirty  minutes  later  both  pupils  became 
dilated,  the  right  more  so  than  the  left;  general  muscular 
twitching  at  the  end  of  an  hour,  and  in  fifteen  minutes 
more  death  from  pulmonary  oedema ;  temperature  post 
mortem,   100.6°. 

Lesions. — Hsematoma  in  right  temporal  region  infil- 
trating temporal  muscle ;  thick  clot  upon  left  side  of 
vertex,  crossing  the  median  line,  and  extending  from 
coronal  to  lambdoid  suture ;  fragment  of  lead  in  external 


512  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

wound;  osseous  entrance  three-eighths  inch  in  diameter; 
no  Assuring  or  comminution.  Bullet  passed  directly 
through  the  parietal  cortex,  fractured  the  anterior  inferior 
portion  of  the  left  parietal  bone,  and  was  then  deflected 
downward  and  a  little  forward  for  two  and  one-half  inches, 
nearly  to  the  cerebral  base  and  near  the  corpus  striatum ; 
track  three-eighths  inch  wide.  No  powder  grains  de- 
tected within  the  intracranial  cavity;  no  epidural  hemor- 
rhage; moderate  cortical  hemorrhage  at  the  vertex; 
moderate  general  hypersemia.  Left  parietal  bone  com- 
minuted and  fragments  elevated  in  space  of  one  and  one- 
fourth  inches  by  five-eighths  of  an  inch. 

Case  CLXXX^^.  Symptoms. — Profound  unconscious- 
ness, profuse  hemorrhage,  and  almost  immediate  death. 

Lesions. — External  wound  one-half  inch  above  and 
one-half  inch  behind  the  right  external  angular  process, 
five-eighths  of  an  inch  in  diameter,  edges  lacerated,  and 
occluded  by  a  protruding  coagulum;  smoke  stain,  three 
inches  in  length  and  one  and  one-half  inches  in  width, 
above  the  supra-orbital  ridge;  no  unburned  grains  of 
powder  upon  the  surface  or  embedded  in  the  skin ;  no 
burns,  fibres  of  the  occipito-frontalis  muscle  blackened 
and  mfiltrated  with  blood;  osseous  wound  circular  and 
one-fourth  of  an  inch  in  diameter,  just  above  the  orbital 
process  of  the  temporal  bone;  slight  staining  of  the  bone 
and  dura  mater,  and  one  or  two  grains  of  powder  ly- 
ing upon  the  orbital  plate.  The  bullet,  of  0.32  cal., 
traversed  the  anterior  extremity  of  the  fissure  of  Sylvius 
and  both  lateral  ventricles,  and,  having  lacerated  the  dura 
mater  and  comminuted  the  bone,  rested  upon  the  left 
parietal  surface.  One  osseous  fragment  was  carried  into 
the  right  frontal  lobe,  and  several  others  were  removed 
from  the  ball  track  near  its  termination.  The  laceration 
of  the  right  frontal  lobe  and  of  the  ventricles  was  ver)' 
great,  but  the  brain  track  near  the  parietal  exit  was  not 
larger  than  the  bullet.  The  left  squamous  and  inferior 
parietal  portions  of  bone  were  comminuted  in  an  area  of 


CASES   VERIFIED    BY   NECROPSY.  513 

nearly  two  inclies,  and  one  fragment  was  elevated  to  an 
angle  of  45°;  no  injury  of  the  scalp. 

Encephalic  Injuries  Without  Cranial  Fracture. 

Case  CLXXXI.  Symptovis. — Violent  delirium  for  two 
days;  recurred  on  the  sixth  day,  followed  by  unconscious- 
ness and  hypersesthesia.  Temperature,  103°  to  104°; 
afterward,  100°  to  103°;  final  temperature,  103°.  Death 
in  twelve  days. 

Lesions. — Pial  hemorrhage  over  left  occipital  lobe,  ex- 
tending into  median  fissure ;  subarachnoid  serous  effu- 
sion. 

Case  CLXXXII.  Syviptoms. — None  recognized  till 
fourth  day,  when  there  were  four  unilateral  convulsions. 
A  single  one  occurred  on  the  fifth  day,  and  they  then  con- 
tinued with  increasing  frequency  till  death  on  the  eighth 
day.  Each  one  began  by  a  twitching  of  the  facial 
muscles,  with  head  and  eyes  turned  to  the  left,  and 
extended  to  the  left  arm,  and  finally  to  the  left  hand. 
Temperature  on  admission,  100°;  twelve  hours  later,  103°; 
then  103°  to  104°,  till  sixteen  hours  before  death,  when  it 
rose  to  105°. 

Lesions. — Extensive  laceration  of  right  temporo-sphe- 
noidal  lobe,  with  cortical  hemorrhage  over  whole  right 
hemisphere. 

Case  CLXXXIII.  Symptoms. — Mental  condition  clear, 
but  dazed,  on  admission  to  the  hospital  ten  hours  after 
reception  of  injury;  extreme  muscular  tremor,  followed 
in  two  hours  by  a  general  convulsion ;  from  this  time 
periods  of  general  convulsions,  with  intervals  of  un- 
consciousness or  delirium,  lasting  about  six  hours,  alter- 
nated with  periods  of  quiescence  of  equal  length ;  no  initial 
symptom.     Death  in  two  days. 

Lesions. — Deep  laceration  of  right  frontal  lobe,  an- 
teriorly and  externally,  extending  into  parietal  region; 
cortical  hemorrhage,  covering  right  frontal  lobe,  right 
33 


514  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

parietal  lobe  anterior  to  the  Rolandic  fissure,  and  the 
temporo-sphenoidal  lobe,  both  laterally  and  inferiorly. 

Case  CLXXXIV.  Symptoms — None.  Found  dead  in 
an  upright  position,  leaning  against  a  fence. 

Lesions. — Lacerations  and  contusions  covering  greater 
part  of  left  frontal  and  temporo-sphenoidal  lobes ;  cortical 
hemorrhage  over  the  whole  left  hemisphere. 

Case  CLXXXV.  Symptoms. — Coma;  stertor;  contrac- 
tion of  pupils;  full  pulse;  rapid  respiration.  Tempera- 
ture, 101°-}-.  On  the  third  day  coma  more  profound; 
dysphagia;  continued  irritability  and  restlessness.  Tem- 
perature, 104.5°.  Death  in  four  days;  temperature, 
107.4°. 

Lesions. — Small  laceration  at  left  parieto-occipital  junc- 
tion ;  cortical  hemorrhage  over  posterior  part  of  left 
parietal  lobe ;  general  hyperaemia. 

Case  CLXXXVI.  Symptoms.  —  Coma,  restlessness, 
and  general  hyperaesthesia ;  temperature,  103.4°;  pneu- 
monia discovered  on  the  second  day.  Death  on  the  third 
day. 

Lesions. — General  hyperaemia,  with  some  punctate 
extravasations;  organized  membranous  effusion,  studded 
with  calcareous  nodules,  over  left  hemisphere. 

Case  CLXXXVII.  Symptoms. — Sudden  coma;  ster- 
tor; double  facial  paralysis;  complete  right  hemiplegia 
and  hemianaesthesia ;  temperature,  99°  to  103°.  Trephi- 
nation, and  drainage  of  serous  effusion  from  the  base  by 
position  of  the  head,  were  followed  within  six  hours  by 
return  of  consciousness,  mental  clearness,  power  of  articu- 
lation, and  decline  of  temperature  to  98.6°,  and  this  im- 
provement in  condition  continued  fourteen  hours;  slight 
chill  then  preceded  a  progressive  rise  of  temperature  to 
104.6°,  and  death  occurred  ten  hours  later. 

Lesions. — Interior  of  left  occipital  lobe  disintegrated  by 
apoplectic  clot,  which  extended  into  both  lateral  ven- 
tricles ;  consequent  fall  from  a  cab  caused  a  laceration  of 
external  border  of  right  cerebellum  and  cortical  hemor- 


CASES    VERIFIED    BY    NECROPSY.  515 

rhage,   which   spread  over   the  pons   into   the  transverse 
fissure. 

Case  CLXXXVIII.  Symptoms. — Xo  primary  general 
symptoms;  temperature,  100°.  Second  day,  delirium. 
Fourth  and  fifth  days,  headache.  Sixth  day,  restlessness, 
irritability,  and  failing  strength  ;  mind  clear.  Eighth  day, 
general  muscular  rigidity,  most  marked  in  right  side  and 
arm,  and,  a  few  hours  previous  to  death,  perforating  ulcer 
of  the  cornea.  Temperature,  second  day,  103.2°;  third 
day,  101°  to  100.8^;  fourth  and  fifth  days,  103.4°  to  103°; 
sixth  da3%  106.4°;  seventh  and  eighth  days,  105°  to  105.2°. 

Lesions. — General  hypersemia;  minute  thrombosis  and 
moderate  oedema,  markedly  involving  basic  ganglia  and 
cerebellum,  and  most  pronounced  on  left  side;  thrombi 
filled  both  lateral  and  both  inferior  petrosal  sinuses,  and 
extended  into  right  jugular  vein,  and  were  decolorized 
only  near  the  torcular  Herophili. 

Case  CLXXXIX.  Symptoms.  —  Delirium ;  normal 
pupils  and  respiration;  temperature,  101.4°;  pulse,  114. 
Later,  excessive  sensitiveness  and  irritability.  The 
delirium  continued,  though  it  did  not  prevent  rational 
reply  to  questions;  temperature  rose  to  103.2°  on  the  fifth 
day,  and  afterward  fell  very  gradually  to  100°;  on  the  four- 
teenth da}^  it  was  103.4°;  and  on  the  fifteenth,  five  hours 
ante  mortem,  it  was  103.8%  and  one  hour  post  mortem  it 
was  104.2°. 

Lesions. — Pial  hemorrhage  over  both  hemispheres  and 
in  largest  quantity  over  parieto-occipital  junctions;  some 
subarachnoid  serous  efiusion  in  left  frontal  region;  gen- 
eral hyperemia  with  punctate  hemorrhages,  most  marked 
on  left  side. 

Case  CXC.  Symptoms. — Primary  unconsciousness;  on 
admission,  forty-eight  hours  later,  muttering  stupor; 
rigidity  of  left  arm;  incomplete  right  hemiplegia,  more 
marked  in  upper  extremities-  pulse,  60;  temperature, 
101°.  Third  day,  increased  rigidity  of  left  arm:  complete 
hemiplegia;    profound    coma;    pulse,     12 8;     temperature, 


5l6  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

105°.  Trephination  was  followed  by  increased  freedom  of 
movement  and  by  some  power  of  articulation.  Death  on 
the  fourth  day. 

Lesions. — ^Moderate  subarachnoid  serous  effusion  over 
anterior  two-thirds  of  right  hemisphere ;  laceration  of  left 
temporo-sphenoidal  lobe,  excavating  and  destroying  its 
whole  structure ;  cortical  hemorrhage  extending  around 
circle  of  Willis  and  upward  upon  occipital  lobe,  and  in 
patches  upon  frontal  and  parietal  lobes. 

Case  CXCI.  Symptoms. — No  external  evidence  of  in- 
jury; coma,  stertor;  rigidity  of  right  side;  pulse,  120; 
temperature,  100°.  Death  on  third  day;  temperature, 
103.2°. 

Lesions. — Large  subarachnoid  serous  effusion;  recent 
clot  in  substance  of  left  cerebellum.  An  old  laceration 
existed  upon  antero-superior  surface  of  left  occipital  lobe 
and  another  upon  its  inferior  surface. 

Case  CXCII.  Symptoms. — Consciousness  lost,  and  par- 
tially restored  before  admission,  twenty-four  hours  later; 
mental  condition  rational,  but  comprehension  slow ;  slight 
dilatation  of  left  pupil.  Temperature,  99°,  followed  by 
some  left  paresis  and  by  some  dysphagia  referred  to  the 
left  side  of  the  throat.  The  patient  from  the  time  of 
injury  often  fell  out  of  bed,  always  on  the  right  side. 
Subsequently  transient  facial  paralysis  occurred ;  amount 
of  paresis  and  of  dilatation  of  left  pupil  varied  from  day  to 
day ;  mental  condition  deteriorated.  Temperature  for  ten 
days  was  99°+ 5  later,  100°+  to  101°;  pulse  and  respira- 
tion nearly  normal.  Trephination  on  the  fifteenth  day 
discovered  a  small  subcortical  cavity  in  the  right  leg  area 
containing  less  than  a  drachm  of  yellowish  fluid,  afterward 
found  to  contain  leucocytes.  The  temperature  was  99°+ 
till  eleventh  day  after  operation,  when  it  rose  to  104°;  next 
day,  101°  to  104°.  Death  from  asthenia  on  the  twenty- 
eighth  day  after  admission. 

Lesions. — Large  subarachnoid  serous  effusion  compress- 
ing frontal  lobes;    general  hyperaemia  with  minute  coag- 


CASES   VERIFIED    BY   NECROPSY.  517 

ula.  The  brain  substance  around  the  small  subcortical 
cavity  opened  during  life  was  softened  and  contained  punc- 
tate extravasations. 

Case  CXCIII.  Symptoms.  —  Unconsciousness,  which 
still  continued  upon  admission  on  the  second  day ;  slight 
dilatation  of  the  pupils ;  complete  left  hemiplegia  and 
hemianaesthesia ;  slight  left  facial  paralysis.  Tempera- 
ture, 106°;  pulse,  140;  respiration,  30;  general  convul- 
sions beginning  soon  after  admission,  and  frequently 
repeated;  initial  symptom  in  mouth  and  lower  face. 
Trephination  same  day  by  house  surgeon  with  negative 
result.  Temperature  two  hours  later,  107.4°.  Death  in  a 
convulsion  five  hours  after  operation.  Temperature, 
forty-five  minutes  post  mortem,  109.4°. 

Lesions. — General  hyperaemia  of  the  brain  and  mem- 
branes ;  tumor  of  the  size  of  a  pea  resting  in  a  small  cavity 
in  the  left  frontal  lobe  formed  by  disintegration  of  sur- 
rounding brain  tissue. 

Case  CXCIV.  Symptoms.  —  Condition  alcoholic  and 
habit  epileptic ;  fell  in  an  epileptic  convulsion ;  large 
haematoma  over  left  frontal  and  parietal  region ;  three 
convulsions  within  first  six  hours,  the  last  followed  by 
partial  paralysis  of  left  lower  face.  The  temperature  on 
the  first  day  was  101.8°,  102.8°,  100°;  second  to  sixth  days 
inclusive,  100.6°  to  i02°-j-;  seventh  to  ninth  day,  normal; 
and  then  for  ten  days  subnormal  during  the  greater  part 
of  each  twenty-four  hours.  On  the  thirteenth  day  a  severe 
chill  was  followed  by  temporary  rise  of  temperature  to 
ioi°+;  and  on  the  nineteenth  daj^  a  slighter  chill  by  an 
elevation  of  temperature,  w^hich  progressively  increased 
till  death,  on  the  twenty-first  day.  Until  the  occurrence 
of  the  second  chill  there  were  few  general  symptoms; 
some  remaining  paresis  and  anaesthesia  of  the  right  face, 
more  or  less  mental  aberration,  and  some  delusions. 
After  the  second  chill  strength  diminished,  the  mental 
condition  became  sluggish,  the  respiration  rapid,  and  tem- 
perature rose  to  105.5°. 


5l8  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

Lesions. — Subcortical  laceration  and  excavation  of  left 
pre-frontal  lobe,  with  a  prolongation  backward  to  a  point 
opposite  to  the  middle  of  the  corpus  striatum ;  no  hemor- 
rhages ;  large  subarachnoid  serous  effusion  and  opacity  of 
the  arachnoid  membrane  over  the  whole  vertex;  general 
hypersemia  and  oedema. 

Case  CXCV.  Symptoms.  —  Consciousness  retained ; 
wound  in  right  parietal  region ;  condition  alcoholic ;  heavy 
sleep  during  the  first  night  after  admission ;  afterward 
constant  restlessness ;  some  pain  in  the  back  of  the  head ; 
vomiting  of  everything  taken  into  the  stomach ;  temper- 
ature on  admission,  102.6°;  second  day,  105°;  and  at  time 
of  death,  which  occurred  somewhat  suddenly  at  the  end  of 
the  third  day,  103.8°;  pulse  moderately  accelerated,  vary- 
ing from  120  to  88;  pupils  and  respiration  normal. 

Lesions. — Subarachnoid  purulent  effusion  over  both 
frontal  lobes,  mainly  on  the  left  side,  with  some  general 
oedema  of  the  pia  mater ;  scanty  fibrinous  exudation  at  the 
base ;  and  fibrinous  patches  on  inner  surface  of  the  dura  at 
the  convexity. 

Case  CXCVI.  Sy?nptoms. — Absolute  unconsciousness 
till  death,  one  hour  and  a  half  after  reception  of  the 
injury ;  small  wound  behind  the  right  ear ;  dilatation  and 
immobility  of  both  pupils;  respiration  on  admission,  42; 
an  hour  later,  2 1 ;  ceased  at  death  rather  suddenly ;  no 
cyanosis ;  pulse  feeble  and  soon  became  imperceptible ; 
temperature  on  admission,  98.6°;  an  hour  later,  98.2°. 

Lesions. — Force  transmitted  through  the  feet  and  lower 
extremities;  fractures  of  both  tarsi,  comminution  of  both 
calces  and  right  astragalus,  fracture  of  left  leg,  and  con- 
tusion of  soles  of  both  feet ;  pial  hemorrhage  to  extent  of 
several  ounces  of  fluid  blood,  mainly  at  the  vertex  and  in 
larger  part  on  the  left  side,  extending  into  median  fissure, 
and  which  had  broken  through  into  the  arachnoid  cavity; 
also  in  considerable  quantity  upon  the  inferior  surface  of 
the  cerebellum,  about  the  median  line,  and  covering  the 
pons;  no  lacerations;  excessive  general  hyperaemia,  most 


CASES   VERIFIED    BY    NECROPSY.  519 

Strongly  marked  on  the  left  side  and  in  the  pons,  optic 
thalami,  and  corpora  striata,  in  the  order  named ;  throm- 
bosis of  minute  vessels  generally,  but  most  pronounced 
in  the  optic  thalami  and  pons;  oedema  of  the  pons. 

Case  CXCVII.  Syinptoms.  —  Primary  unconscious- 
ness ;  and  on  admission  mind  confused  and  speech  discon- 
nected ;  four  general  convulsions  from  twelve  to  twenty- 
four  hours  afterward  ;  no  control  of  urine  or  faeces ;  second 
day,  semi-consciousness ;  muscular  rigidity  in  back  of  the 
neck  and  extremities;  some  irritability;  fourth  day, 
mental  condition  rational,  but  no  remembrance  of  the 
manner  in  which  the  injury  had  been  received.  During 
the  next  ten  days  the  urine,  but  not  the  faeces,  remained 
uncontrolled ;  there  was  noticeable  weakness  of  the  mus- 
cles of  the  trunk,  inability  to  rise  or  sit  up  in  in  bed  with- 
out assistance,  dementia  and  loss  of  memory,  primary 
union  of  the  wound,  and  nearly  normal  pulse  and  respira- 
tion. On  the  fifteenth  day  there  was  somnolence  and 
increase  in  temperature  and  infrequency  of  the  pulse  and 
respiration;  stupor  deepened,  and  on  the  seventeenth  day 
unconsciousness  was  complete.  Death  occurred  in  eigh- 
teen days.  Temperature  on  admission,  99.4°;  fourth  day, 
99°;  till  the  end  of  second  week,  99°  to  ioo°-|-;  on  the 
seventeenth  day,  102.7°  to  i03-8°;  on  the  eighteenth  day, 
105.4°.  Pulse  on  admission,  96;  normal  till  fifteenth  day 
later,  160.     Respiration  on  admission,  26. 

Lesions. — Haematoma  over  right  parietal  eminence 
thrombus  in  superior  longitudinal  sinus ;  great  fulness 
of  meningeal  veins  over  vertex;  convolutions  flattened 
frontal  lobes  relatively  small,  parietal  lobes  bulging  as 
though  from  distention ;  general  cerebral  hyperasmia  and 
oedema  without  punctate  extravasations  and  with  few 
minute  thrombi ;  substance  of  cerebellum  nearly  normal. 
By  compressing  posterior  portion  of  the  cerebrum  and 
making  vertical  sections  anteriorly,  serous  fluid  exuded 
in  great  quantity;  little  serum  in  the  ventricles.  A  clot 
about  the  size  of  a  large  pea  and  of  elliptical  form  occu- 


$20  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

pied  the  exact  centre  of  the  anterior  third  of  the  left  optic 
thalamus.  There  were  no  other  lacerations,  and  no 
hemorrhages  or  subarachnoid  effusions,  and  upon  micro- 
scopical examination  no  inflammatory  changes. 

Case  CXCVIII.  SymptoDis. — Walking  case;  uncon- 
sciousness supervened  some  hours  after  injury,  and  con- 
tinued till  death  on  the  third  day;  wounds  in  occipital  and 
both  parietal  regions;  slight  dilatation  of  left  pupil. 
Temperature,  103.6°  to  106.6°. 

Lesions. — Large  pial  hemorrhage  compressing  left 
fronto-parietal  region ;  excessive  general  hyperaemia  with 
numerous  minute  thromboses ;  subcortical  laceration  just 
external  to  anterior  part  of  left  corpus  striatum,  one  inch 
by  half  an  inch  in  its  diameters. 

Case  CXCIX.  Syviptoms.  —  None  recognized  till  ad- 
mission three  days  after  reception  of  the  injury ;  partial 
loss  of  consciousness;  complete  right  hemiplegia  and 
hemianaesthesia  including  trunk;  complete  aphonia; 
slight  dilatation  of  pupils;  bilateral  convulsive  movements 
of  face  and  neck  with  the  eyes  turned  to  the  right, 
repeated  every  five  minutes;  respiration  shallow  and 
hurried ;  pulse  rapid,  feeble,  and  irregular.  Tempera- 
ture, 101°  to  104°;  radial  pulsation  fuller  and  stronger  on 
the  left  side  than  on  the  right.  Trephination  disclosed 
arachnoid  clot.  Death  occurred  before  operation  was 
completed. 

Lesions. — Pial  hemorrhage  with  clot  covering  both 
frontal  and  both  parietal  lobes;  right  lateral  ventricle 
filled  with  hemorrhagic  serous  effusion ;  general  hyper- 
aemia. 

Case  CC.  Symptoms.  —  Walking  case ;  unconscious- 
ness supervened  some  hours  after  apparently  trivial 
injury;  no  discoverable  external  lesion;  dilatation  of 
pupils;  second  day,  partial  restoration  of  consciousness; 
fourth  day,  delusions;  ninth  day,  stupor;  eleventh  day, 
complete  unconsciousness.  Death  at  end  of  twelfth  day. 
Temperature  on  first  day,    102.4°;  afterward,  101°  to  99°; 


CASES   VERIFIED    BY    NECROPSY.  52 1 

final  observation,   100.8°;   pulse,  "6'',  gradually  increasing 
in  frequency;  respiration,  24,  20,  28. 

Lesions. — Thin  layer  of  pial  hemorrhage  which  covered 
the  opposing  surfaces  of  the  superior  median  fissure,  and 
spread  over  left  occipital  and  parietal  lobes  to  margin  of 
temporal  lobe;  some  blood,  also  pial,  in  left  middle  fossa; 
general  hyperasmia  and  moderate  oedema. 

Case  CCI.  Syuiptoms.  —  Unconsciousness  vhich  soon 
after  admission  was  replaced  by  delirium ;  no  external 
injury ;  loss  of  urinary  control ;  delirium  constant,  of  a 
quiet  sort  by  day  a  d  violent  by  night  till  the  seventh  day, 
when  for  some  hours  before  death  it  was  muttering,  or 
typhoid,  in  character;  mental  condition  stupid  from  the 
beginning;  patient  was  at  no  time  able  to  give  any 
account  of  himself,  to  respond  to  a  question,  or  to  show 
any  appreciation  of  his  surroundings.  Death  from  as- 
thenia on  the  seventh  day.  Temperature  on  admission, 
96.2°;  rose  progressively  in  three  days  to  103.2°;  on  the 
fourth  day  was  101,8°;  on  the  fifth  day,  103°;  on  the 
sixth  day,  104.6°;  and  on  the  seventh  day,  101.2°  to 
107.2°;  post  mortem,  107.8°.  The  pulse  did  not  exceed 
100  till  late  in  the  week. 

Lesions. — Small  laceration  in  the  substance  of  the  pos- 
terior part  of  the  left  frontal  lobe  ;  laceration  of  under  part 
of  the  corpus  callosum  in  its  anterior  third,  and  of  left 
lateral  edge  of  the  fornix  anteriorly;  small  hemorrhage 
in  left  lateral  ventricle  derived  from  the  laceration  of  the 
fornix;  pial  hemorrhage  over  posterior  part  of  right  oc- 
cipital lobe,  upon  its  border,  beneath  tentorium,  and  upon 
the  posterior  border  of  the  cerebellum  :  blood  fluid  and 
moderate  in  am^ount;  moderate  general  hypersemia  with 
minute  thromboses. 

Case  CCII.  Symptoms. — Walking  case;  unconscious- 
ness after  some  hours'  interval;  stertor;  loss  of  urinary 
control;  vomiting.  Temperature,  101.8°;  rose  progres- 
sivel)^  to  107.8°;  pulse,  70  to  162;  respiration,  24  to  46. 
Death  in  eleven  hours. 


522  INJURIES   OF   THE    BRAIN    AND    MEMBRANES. 

Lesions. — Laceration  of  superior  surface  of  right  pari- 
etal lobe ;  cortical  hemorrhage  covering  whole  right  hemi- 
sphere;  general  hyperaemia. 

Case  CCIII.  Symptoms.  —  Unconsciousness,  which 
soon  became  profound;  normal  pupils;  pulse  in  a  few 
moments  rose  from  90  to  140;  right  side  of  body  and  right 
extremities  rigid;  bilateral  convulsive  movements;  right 
radial  pulse  fuller  and  stronger  than  the  left.  Death  in 
eight  hours  and  a  half.  Temperature  on  admission,  97°; 
in  three  hours,  101°;  in  six  hours,  102,2°;  pulse  90  to  140  to 
136;  respiration,  20,  18,  21  ;  and  just  before  death,  12  and 
then  7  in  the  minute,  very  full  and  deep,  with  cyanosis. 

Lesions. — Small  contusion  of  scalp  in  left  middle 
parietal  region  discovered  only  after  post-mortem  incision  ; 
thin  pial  hemorrhage,  mostly  fluid,  covered  whole  su- 
perior and  external  surfaces  of  both  hemispheres  as  far 
forward  as  the  middle  of  the  frontal  lobes,  extended  in 
larger  quantity  over  both  surfaces  and  both  borders  of  the 
cerebellum,  and  spread  over  the  pons  and  medulla;  pia 
mater  intensely  hyperaemic ;  small  contusion  on  inner  bor- 
der of  right  temporo-sphenoidal  lobe,  and  a  larger  one 
at  left  parieto-occipital  junction ;  brain  substance  gener- 
ally excessively  hyperaemic  and  oedematous,  with  many 
small  areas  of  local  contusion  filled  with  small  hemor- 
rhages as  large  as  a  robin-shot. 

The  essential  lesion  was  laceration  of  the  basic  ganglia. 
The  right  corpus  striatum  was  entirely  disintegrated  and 
destroyed ;  its  ventricular  surface  only  remained,  as  a 
ragged  membranous  capsule,  of  which  much  had  alto- 
gether disappeared.  The  laceration  extended  antero- 
laterally  into  the  substance  of  the  right  frontal  and 
parietal  lobes;  it  was  continued  posteriorly  through  the 
taenia  semicircularis  into  the  anterior  part  of  the  optic 
thalamus.  The  ventricular  surface  of  the  left  corpus 
striatum  was  contused  and  marked  by  small  linear  lacera- 
tions. The  fornix  and  under  surface  of  the  corpus  cal- 
losum   were    softened    and    disintegrated.       Fluid   blood 


CASES   VERIFIED    BY   NECROPSY.  523 

partly  filled  both  lateral  ventricles,  and  in  the  left  had 
broken  through  the  posterior  cornu  into  the  occipital  lobe 
in  considerable  quantity. 

Case  CCIV.  Symptoms. — Immediate  unconsciousness 
with  some  response  to  external  irritations,  which  con- 
tinued till  final  coma;  continued  dilatation  of  both  pupils, 
which  were  sensitive ;  temporary  rigidity  of  left  side ; 
right  hemiplegia  and  hemianaesthesia,  and  right  facial 
paralysis ;  restlessness,  which  was  confined  to  the  left 
side;  retention  of  urine;  coma  and  stertor  for  five  hours 
before  death,  which  occurred  in  fifty-three  hours.  Six 
hours  before  death  the  left  hand  became  icy  cold  and  the 
left  arm  and  foot  cool,  while  other  parts  of  the  body 
retained  a  normal  surface  temperature.  At  this  time  the 
rectal  temperature  was  102.6°;  the  left  axillary,  100.4°; 
and  the  right  axillary,  103.2°.  In  fifteen  minutes  the 
temperature  in  the  left  axilla  rose  to  101.4°,  and  in  thirty 
minutes  to  102.8°,  while  the  rectal  and  right  axillary  tem- 
peratures remained  stationary.  The  axillary  temperatures 
were  at  other  times  symmetrical.  Temperature  on  admis- 
sion was  98.5°,  and  in  two  hours,  102.2°;  in  eleven  hours 
it  receded  to  101°,  in  the  next  twelve  hours  rose  to  105°, 
on  the  second  day  receded  to  100.4°,  and  a  few  moments 
before  death  was  106°;  one  hour  post  mortem,  106.2°. 
The  pulse  gradually  increased  in  frequency  from  no  to 
158.  The  respiration  was  never  below  30,  and  was  finally 
56  in  the  minute. 

Lesions. — Contused  wound  of  the  scalp  over  right 
parietal  eminence;  slight  pial  hemorrhage  over  inferior 
surface  of  cerebellum  and  posterior  left  occipital  border; 
copious  subarachnoid  effusion  and  arachnoid  opacity  in 
posterior  parietal  regions  most  marked  on  the  left  side; 
small  hemorrhagic  serous  effusion  in  left  lateral  ventricle ; 
limited  contusion  and  slight  laceration  in  the  substance  of 
the  fornix  posteriorly;  excessive  general  hyperasmia  and 
oedema,  with  a  few  minute  thrombi  in  all  parts  of  the 
brain. 


524  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

Case  CCV.  Symptoms. — The  patient  walked  home 
after  a  fall  of  ten  feet,  had  a  single  convulsion  a  few  hours 
later,  and  was  stupid  or  dazed  for  five  days  afterward ;  he 
then  became  violently  delirious,  and  was  admitted  to  the 
hospital.  At  that  time,  no  visible  external  injury ;  pu- 
pils moderately  dilated;  opposite  radial  pulsations  sym- 
metrical ;  posterior  cervical  muscular  rigidity,  and  loss  of 
urinary  control.  On  the  following  (seventh)  day  pupils 
contracted,  and  muscular  rigidity  increased ;  one  convul- 
sion after  admission ;  mental  condition  marked  by  alterna- 
tions of  stupor,  with  wild  delirium.  No  change  till  the 
eleventh  day,  when  the  patient  became  quieter,  and  could 
answer  a  limited  number  of  questions  intelligently.  On 
the  fifteenth  day  the  pupils  became  normal,  muscular 
rigidity  diminished,  and  urinary  control  was  temporarily 
regained.  From  the  sixteenth  day  unconsciousness  was 
complete.  On  the  seventeenth  day  the  pupils  were  again 
contracted,  the  respiration  was  stertorous,  and  the  face  cya- 
notic; the  lungs  became  oedematous,  and  death  occurred 
on  the  morning  of  the  nineteenth  day.  The  temperature 
on  admission  was  102°,  and  varied  from  99°  to  ioi°-(-  with 
occasional  elevations  to  102"^-!-  till  the  last  thirty-six  hours, 
when  it  was  constant  at  105.6°;  and  half  an  hour  post 
mortem  was  106°.  The  pulse  on  admission  was  132,  and 
afterward  was  usually  from  96  to  112.  The  respiration 
was  moderately  increased  in  frequency.  Both  pulse  and 
respiration  were  finally  greatly  accelerated. 

Lesions. — Cortical  hemorrhage,  compressing  outer  and 
anterior  aspect  of  right  frontal  lobe,  and  filling  right  an- 
terior fossa.  This  was  derived  from  a  laceration  of  the 
inferior  surface  of  the  right  frontal  lobe,  mainly  subcor- 
tical, which  excavated  its  inferior  and  outer  portion ; 
cavity  as  large  as  a  pigeon's  q^%  and  lined  by  a  thin, 
chocolate-colored,  and  pultaceous  substance.  Small  linear 
laceration  upon  inner  border  of  left  frontal  lobe  and  slight 
contusion  of  anterior  portion  of  right  temporo-sphenoidal 
lobe,   both    upon    inferior   surface;    opacity   of   arachnoid 


CASES   VERIFIED    BY   NECROPSY.  525 

membrane;  no  subarachnoid  serous  effusion,  and  only  very 
moderate  hyperaemia  of  the  brain  substance. 

Case  CCVI.  Sy^nptoms.  —  Primary  and  permanent 
unconsciousness  ;  restlessness ;  general  muscular  rigidity  ; 
stertor;  irregular  pupils.  Temperature  on  admission, 
100°,  and  at  death  99.8^;  pulse  varied  from  108  to  160 ; 
respiration,  32  to  58.     Death  in  an  hour  and  a  half. 

Lesions. — No  fracture  or  lacerations ;  large  general 
subarachnoid  and  ventricular  serous  effusion;  general 
hyperaemia  and  excessive  oedema. 

Case  CCVII.  Symptoms. — Patient  in  an  alcoholic  con- 
dition ;  said  to  have  been  injured  tvo  days  previously; 
stupid,  but  could  Avalk  and  ansver  questions.  On  admis- 
sion to  the  hospital  temperature  98. 5"";  rose  progressively 
to  i02°-|-  at  time  of  death.  On  second  day,  deep  coma, 
pupils  normal,  pulse  began  to  grow  veaker;  no  other 
symptoms  till  sixth  day,  when,  just  before  death,  res- 
piration became  of  the  Cheyne-Stokes  variety. 

Lesions. — Xo  injury  of  scalp  or  skull.  Pia  mater 
cloudy  and  much  injected;  pial  hemorrhage  on  the  right 
side,  over  posterior  third  of  first  and  second  frontal,  and 
upper  third  of  ascending  frontal  convolutions ;  on  the  left 
side  it  involved  only  posterior  third  of  first  frontal ;  a  clot 
about  the  size  of  a  pea  in  the  substance  of  the  left  gyrus 
fornicatus,  about  its  middle  portion ;  brain  substance 
very  hyperaemic ;  no  lesions  of  thoracic  or  abdominal 
viscera  except  commencing  pericarditis. 

Case  CCVI II.  Symptoms.  —  Temporary  unconscious- 
ness, followed  by  coma  and  stertor  two  hours  later,  and  in 
another  hour  by  a  convulsion,  beginning  with  tonic  spasm 
of  the  arms  and  legs,  and  succeeded  by  others  at  short  inter- 
vals till  admission  to  the  hospital  nine  hours  after  receipt 
of  injury.  Twenty-two  convulsions  occurred  from  this 
time  till  death  at  the  end  of  twelve  hours.  Each  began 
upon  the  right  side  of  the  face  and  extended  to  the  ex- 
tremities of  the  left  side;  eyes,  with  the  head  and  neck, 
turned  to  the  left;    sometimes  the  right  pupil  only,  and 


526  IN'JURIES    OF   THE    BRAIN   AND    MEMBRANES. 

sometimes  both  pupils,  dilated.  Consciousness  was  never 
regained.  Temperature  on  admission,  ioi°;  fell  to 
100.2°,  and  rose  to  101°  at  death;  thirty  minutes  post 
mortem,  100.6°;  pulse,  120,  96,  128;  respiration,  20, 
16,  28,  15. 

Lesions. — Xo  injury  of  scalp  or  cranium;  dura  mater 
congested ;  pial  hemorrhage  over  whole  left  hemisphere, 
and  in  left  posterior  and  middle  basic  fossae ;  clot  thickest 
over  left  motor  area;  actual  weight  of  clot,  three  ounces; 
brain  substance  hyperaemic ;  serous  effusion  in  each  lateral 
ventricle ;   basic  arteries  atheromatous. 

Case  CCIX.  Symptoms.  —  Patient  said  to  have  had 
attacks  of  faintness  or  vertigo  for  a  length  of  time,  in  one 
of  which  he  fell  down  a  flight  of  stairs  and  fractured  a 
cervix  femoris.  He  became  momentarily  unconscious,  and 
after  a  little  interval  was  again  unconscious  for  one  or 
two  hours.  On  admission  to  the  hospital  three  days  later 
no  intracranial  lesion  was  recognized.  His  temperature 
but  once  exceeded  99°.  Seven  weeks  afterward  while 
crossing  the  ward  he  fell,  striking  upon  the  back  of  his 
head.  Both  pupils  were  moderately  contracted  but  un- 
.symmetrical.  After  an  interval  of  thirty  minutes  he 
became  temporarily  unconscious;  pulse  remained  weak 
and  frequent;  temperature  did  not  exceed  101°;  left  arm 
was  raised  more  slowly  than  the  right;  and  death  occurred 
in  twenty  hours. 

Lesions. — Recent:  meningeal  and  cortical  vessels  much 
injected;  arachnoid  opacity  and  turbid  yellowish  sub- 
arachnoid serous  effusion  at  the  vertex ;  some  serous  effu- 
sion in  both  lateral  ventricles ;  brain  substance  hyperaemic. 
The  heart  was  fatty,  its  right  side  dilated,  and  its  coro- 
nary arteries  thickened  and  rigid.  The  liver  and  kid- 
neys were  cirrhotic,  and  there  were  points  of  pulmonary 
hemorrhage.  Old :  a  cavity,  one  inch  by  one-half  inch  in 
diameter,  and  nearly  filled  with  a  pinkish  pultaceous 
material,  and  in  process  of  contraction,  was  found  just 
beneath  the  cortex  and  just  above  the  horizontal  arm  of 


CASES   VERIFIED    BY    NECROPSY.  527 

the  right  fissure  of  Sylvius.  A  similar  cavity  of  half  the 
size  was  situated  a  little  anterior  to  the  first. 

Case  CCX.  Symptoms.  — No  loss  of  consciousness  fol- 
lowed injury ;  one  convulsion  occurred  five  or  six  hours 
later.  On  admission  to  the  hospital  on  the  following  day, 
mental  condition  stupid,  speech  incoherent,  pupils  con- 
tracted, radial  pulsations  symmetrical,  and  a  scalp  wound 
in  the  parieto-occipital  region.  Temperatme,  98.2°;  pulse, 
86;  respiration,  32.  Stupor  continued  with  slight  general 
convulsions  and  loss  of  urinary  and  faecal  control.  Tem- 
perature rose  to  102°,  and  on  the  second  day  to  104°;  no 
further  convulsions.  On  the  third  day  the  stupor  was 
replaced  by  restlessness  and  delirium,  which  were  not  con- 
stant but  continued  afterward  the  greater  part  of  each  day 
and  night.  After  the  first  week  the  neck  and  shoulders 
were  quite  stiff  and  sometimes  painful.  The  pupils  were 
normal  or  slightly  contracted;  feecal  and  urinary  control 
was  not  regained.  Strength  failed  rather  suddenly  a  few 
hours  before  death,  which  occurred  on  the  fourteenth  day. 
The  temperature,  from  104°  on  the  second,  subsided  to 
100.6°  on  the  third,  and  to  98.8°  on  the  fourth  day, 
and  subsequently  ranged  from  99°  to  101°.  At  death,  it 
rose  to  102°,  and  thirty  minutes  post  mortem  to  103°. 
The  pulse  varied  from  60  to  90,  and  the  respiration,  after 
the  third  day,  from  20  to  28. 

Lesions. — Scalp  wound  as  noted ;  no  fracture.  At  a 
point  beneath  the  scalp  wound,  the  dura  mater,  arachnoid 
membrane,  and  pia  mater  were  adherent  over  an  area  of 
one  inch  by  one-half  inch,  mainly  on  the  right  side  but 
extending  across  the  median  line.  There  was  consider- 
able subarachnoid  serous  effusion  with  slight  arachnoid 
opacity,  and  the  cortical  vessels  were  injected.  A  cortical 
laceration  of  the  posterior  inferior  border  of  the  right 
occipital  lobe,  not  larger  than  a  pea,  was  surrounded  by 
an  area,  one  inch  in  diameter,  of  dusky  and  greenish- 
colored  cortex;  a  subcortical  laceration  beneath  this  ex- 
tended across  the  whole  posterior  border  of  the  lobe,  and 


528  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

forward  into  the  right  lateral  ventricle,  and  was  filled  with 
disintegrated  coagulum ;  the  cavity  of  the  ventricle  was 
bloodstained  throughout  and  contained  fragments  of  dark- 
colored  clot.  There  was  a  second  dull,  dusky,  and  green- 
ish-colored area,  one  and  a  half  by  three-fourths  of  an 
inch  in  its  diameters,  about  the  centre  of  the  posterior  in- 
ferior border  of  the  left  occipital  lobe,  and  beneath  this 
another  subcortical  hemorrhage  which  excavated  a  large 
part  of  the  lobe  and  opened  into  the  lateral  ventricle ;  the 
appearances  of  this  cavity  and  ventricle  were  similar  to 
those  upon  the  opposite  side.  There  was  no  communica- 
tion between  the  two  cavities  of  laceration.  There  was  a 
little  cortical  hemorrhage  about  the  laceration  upon  the 
right  side  and  a  little  upon  the  superior  surface  of  the 
left  cerebellum,  coming  from  a  slight  laceration  of  its 
external  border.  The  brain  substance  was  moderately 
hypersemic,  with  minute  thrombi  of  the  vessels. 

Case  CCXI.  Symptoms. — Patient  found  in  the  street 
in  an  epileptiform  convulsion.  On  admission  to  the 
hospital,  unconscious  tossing  about  and  frothing  at  the 
mouth,  with  some  rigidity  of  the  limbs,  and  dilated  im- 
movable pupils;  skin  reflexes  absent.  Death  on  the  fol- 
lowing day  without  material  change  in  symptoms  having 
occurred.  Temperature  on  admission,  ioo°,  rose  in  four 
hours  to  io6°  and  in  sixteen  hours  to  106.2°,  and  in  the 
following  sixteen  hours  receded  to  104°;  no  temperature 
taken  in  the  four  hours  immediately  preceding  death. 
Pulse  100,  160,  94.     Respiration,  20,  50,  46. 

Lesions. — No  injury  of  scalp  or  skull;  no  laceration  or 
contusion  of  the  brain.  Slight  subarachnoid  serous  effu- 
sion over  both  posterior  parietal  regions.  About  one 
drachm  of  thin  purulent  effusion  between  the  cerebellar 
lobes  and  upon  their  inferior  surfaces  anteriorly.  Exces- 
sive hyperaemia  and  oedema  of  the  brain,  with  venous 
distention. 

Case  CCXII.  Symptoms. — Patient  had  been  knocked 
down  by  a  wagon,  and  was  semi-conscious  when  admitted 


CASES    VERIFIED    BY    NECROPSY.  529 

to  the  hospital.  Lacerated  and  contused  Avound  of  the  scalp 
in  left  temporal  region ;  pupils  normal ;  no  muscular  or 
sensory  symptoms.  Temperature,  100.5'';  pulse,  90^; 
respiration,  24.  On  the  second  day,  faecal  and  urinary  con- 
trol lost;  slight  increase  of  temperature,  and  apparent  un- 
consciousness, only  broken  by  monosyllabic  cries  when  dis- 
turbed. On  the  third  day,  temperature  102.8°,  104^,  102'; 
pulse,  no;  respiration,  36;  urine  retained,  continued  lack 
of  fsecal  control,  and  mental  condition  sluggish.  Trephina- 
tion and  incision  of  dura  mater  in  front  of  coronal  suture 
%Yith  negative  result;  a  second  trephination,  a  little  above 
and  behind  the  right  ear,  disclosed  a  larger  subdural  clot, 
much  of  which  was  removed,  and  a  laceration  of  the 
brain.  No  material  change  in  the  patient's  condition  for 
eighteen  hours,  when  the  temperature  began  to  rise  from 
102.4°,  with  progressive  increase  to  107.2°  at  death  ten 
hours  later;  pulse,  106,  128;  respiration,  26,  20. 

Lesions. — No  fracture  ;  laceration  of  the  right  temporal 
lobe  and  a  remnant  of  blood  clot  extending  to  base  in  the 
middle  fossa. 

Case  CCXIII.  Symptoms. — Patient  said  to  have  fallen 
in  the  street.  On  admission  to  the  hospital,  stupor, 
wounds  in  the  right  temporal  and  posterior  parietal 
regions,  and  vertigo.  Temperature,  101.2°.-  pulse,  76; 
respiration,  26.  On  the  second  day,  vomiting,  slight  dila- 
tation of  the  pupils,  and  headache ;  mental  confusion,  and 
inabilit}'  of  comprehension ;  answers  to  questions  were 
sometimes  intelligent,  but  mainly  ejaculatory;  mechanical 
restraint  required  for  retention  in  bed ;  temperature, 
102°,  101.4°;  retention  of  urine.  At  the  end  of  the  first 
AYeek  the  temperature,  which  had  ranged  for  three  days 
from  98.8°  to  101°,  suddenly  rose  to  104.6°,  with  an  access 
of  delirium,  and  three  days  later  again  became  nor- 
mal, and  for  the  ensuing  four  days  varied  from  99°+  to 
ioo°-l-;  on  the  fifteenth  day  it  rose  to  103.2°,  and  from 
that  time  was  marked  by  great  irregularities  until  death. 
Fifteenth  day,  103.2°,  100°,  105.6°;  sixteenth  day, 
34 


530  INJURIES   OF   THE    BRAIN    AND    MEMBRANES. 

104.8°,  105.6°,  98.4°  (chill),  105. 6^  101.2°;  seventeenth 
day,  99-8°,  102.4°,  100°,  103.2°;  eighteenth  day,  102°, 
106°,  final. 

The  pulse  and  respiration  were  also  variable,  but 
frequent.  Ten  minutes  before  death  there  were  left 
unilateral  convulsions. 

Lesions. — No  fracture;  large  subcortical  laceration  of 
the  anterior  part  of  the  left  frontal  lobe,  which  formed  an 
excavation,  one  and  a  half  inches  by  three-fourths  of  an 
inch  in  its  diameters,  filled  with  dark-colored  clot;  it  was 
brownish-yellow,  soft  and  ragged :  the  cortex  was  broken 
through  at  the  tip  of  the  lobe.  A  cortical  superficial 
laceration  existed  in  the  centre  of  the  inferior  surface  of 
the  left  cerebellar  lobe,  of  a  chocolate  color,  soft,  with  ill- 
defined  margin,  and  no  apparent  loss  of  tissue.  At  this 
point  the  meninges  were  adherent  to  the  bone.  There 
were  no  hemorrhages;  there  was  marked  general  hyper- 
aemia  and  oedema.  There  was  an  opaque  subarachnoid 
effusion  all  over  both  hemispheres,  which  was  copious  at 
the  base  posteriorly.  The  basilar  arteries  were  somewhat 
atheromatous  and  the  heart  was  thickened,  as  were  the 
aortic  valves. 

Case  CCXIV.  Symptoms. — Patient  fell  five  stories  to 
the  pavement.  Primary  and  permanent  unconsciousness, 
wound  in  right  temporal  region,  hemorrhage  from  both 
nostrils,  slight  twitchings  of  left  arm,  pupils  normal;  tem- 
perature, 99.8°;  pulse,  130;  respiration,  27.  Restlessness 
and  unconsciousness  continued  till  death  thirty-four  hours 
later;  temperature  rose  progressively  to  108'',  with  no  im- 
mediate post-mortem  change 

Lesions. — No  fracture;  small  pial  hemorrhage  over 
lateral  aspect  of  right  temporal  lobe,  and  moderate  gen- 
eral hyperaemia  and  oedema;  no  limited  lesion. 

There  was  a  laceration  of  the  left  kidney  which  had 
been  recognized  during  life. 

Case  CCXV.  Symptoms.  —  Patient  fell  fifteen  feet . 
was  dazed  but  walked  about,  conversed  with  his  associates. 


CASES    VERIFIED    BY    NECROPSY.  53  I 

and  ^-as  not  thought  to  be  seriously  injured.  Half  an 
hour  later  he  became  somnolent,  and  was  taken  to  the 
hospital,  which  he  reached  in  an  entirely  unconscious  con- 
dition;  temperature,  96'';  pulse,  68;  respiration,  12;  right 
pupil  dilated ;  slight  rigidity  of  left  arm  and  leg ;  wound 
in  right  frontal  region,  and  hasmatoma.  Death  in  three 
hours.      Temperature,  97';  pulse,  lOO';  respiration,  10. 

Lesions. — Xo  fracture ;  wound  of  anterior  branch  of 
right  middle  meningeal  artery,  and  consequent  epidural 
hemorrhage,  forming  clot  three  and  one-half  by  three 
inches  in  diameters,  and  one  and  one-half  inches  in  thick- 
ness: brain  moderately  hyperaemic  and  cedematous ;  no 
laceration. 

Case  CCXVI.  Symptoms. — Primary  and  permanent 
unconsciousness,  pupils  slightly  contracted,  right  pulse 
fuller  than  the  left,  hemiplegia  of  the  left  side,  reflexes 
absent,  head  and  eyes  turned  to  the  left.  Death  in  four 
hours. 

Lesions. — Xo  fracture;  laceration  of  the  right  parietal 
lobe,  and  hemorrhage  into  the  lateral  ventricle  and  at  the 
base  of  the  brain. 

Case  CCXVII.  Symptoms. — The  patient  was  knocked 
down  by  a  cable  car.  Temperature,  96.2° ;  pulse,  92  ;  respi- 
ration, 20;  loss  of  consciousness  not  absolute  ;  restlessness, 
no  external  injuries,  and  no  other  pathic  indications. 
During  the  day  temperature  rose  to  101.6°,  and  during  the 
night  patient  was  restless,  noisy,  got  up  and  then  urinated 
in  bed,  and  mechanical  restraint  was  employed.  Death 
occurred  on  the  twenty-third  day.  He  was  usually  quiet 
and  stupid  by  day,  and  restless,  noisy,  and  striving  to  get 
out  of  bed  at  night ;  on  the  fourth  day  there  was  stiffness 
of  the  neck,  and  on  the  fourteenth  day  of  the  arms  and 
legs;  faecal  and  urinary  control  was  lost  on  the  seventh 
day,  and  on  the  twentieth  the  voice  was  thick,  the  head 
extended,  and  the  condition  typhoid.  The  temperature 
on  the  sixth,  seventh,  eighth,  and  ninth  days  was  sub- 
normal,  97.8°,   97. 2^  97.6=,    and  was   afterward   variable, 


532  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

usually  ioi-i02°-|-,  occasionally  rising  to  i03°-io5°. 
The  final  temperature  was  109.2°,  with  no  immediate 
post-mortem  change.  The  pulse,  when  the  temperature 
was  subnormal,  was  from  76  to  100,  and  the  respiration 
normal;  and  in  the  last  five  days  both  were  frequent. 

Lesions. — No  fracture;  deep  laceration,  three-fourths 
of  an  inch  in  length,  upon  inferior  surface  of  left  frontal 
lobe,  and  another  of  the  same  extent  upon  the  inferior 
surface  of  the  left  temporal  lobe,  both  with  excavated 
edges  and  of  a  dirty  brown  color ;  large  cortical  hemor- 
rhage in  middle  and  anterior  fossae ;  area  of  pial  hemor- 
rhage two  inches  in  diameter  over  the  right  motor  area ; 
moderate  subarachnoid  serous  effusion  confined  to  the 
vertex. 

Case  CCXVIII.  Symptoms. — Patient  thrown  from  his 
truck,  his  head  striking  the  pavement.  Primary  and  per- 
manent unconsciousness ;  respiration  slow  and  stertorous ; 
face  intensely  cyanotic,  pupils  normal,  no  muscular  symp- 
toms; wound  in  right  occipital  region;  temperature,  97°; 
pulse,  108  and  weak;  respiration  13.  Coma  deepened, 
surface  grew  cold,  pupils  dilated,  temperature  was  un- 
changed, and  death  occurred  in  fifty  minutes. 

Lesions. — No  fracture;  skull  thick.  Epidural  hemor- 
rhage in  middle  fossae  extending  over  occipital  lobes. 
Brain  oedematous.  The  liver  was  ruptured  with  much 
abdominal  hemorrhage. 

Case  CCXIX.  Symptoms. — Primary  and  permanent 
unconsciousness;  wound  in  left  frontal  region  and  com- 
pound fracture  of  left  leg ;  pupils  normal  but  irresponsive, 
head  and  eyes  turned  to  the  right,  twitching  of  the  left 
corner  of  the  mouth,  abdominal  reflexes  absent,  no  hemor- 
rhages, and  radial  pulsations  symmetrical.  Death  oc- 
curred in  thirty-six  hours  with  no  change  in  symptoms 
but  progressive  asthenia.  Temperature  rose  progressively 
from  96.8°  to  105°;  pulse,  108-190;  respiration,  20-70. 

Lesions. — No  fracture;  skull  very  thick.  Large  pial 
hemorrhage    covering   whole    brain,    except   left    frontal 


CASES   VERIFIED   BY   NECROPSY.  533 

lobe ;  clot  thickest  in  right  parieto-occipital  region ;  no 
laceration ;  general  hypersemia  and  oedema. 

Case  CCXX.  Symptoms.  —  Patient  jumped  from  a 
second-story  window ;  primar)^  and  permanent  loss  of  con- 
sciousness, which  was  complete ;  hemorrhage  from  both 
nostrils;  dilatation  of  both  pupils;  no  muscular  symp- 
toms. On  arrival  of  ambulance,  respiration  was  four  to 
five  in  the  minute,  and  was  said  not  to  have  been  more 
frequent  from  the  moment  of  injury;  it  became  more  in- 
frequent before  reaching  the  hospital,  and  was  finally  not 
more  than  one  in  the  minute.  Death  occurred  a  few 
moments  after  admission  and  in  from  forty-five  to  fifty 
minutes  after  the  injury  was  received.  The  pulse  was 
full  and  strong  and  of  normal  frequency  for  a  little  time 
after  the  cessation  of  respiration. 

Lesions. — No  fracture;  wound  in  left  occipital  region 
with  large  haematoma;  no  epidural  hemorrhage;  pial 
hemorrhage  covering  whole  surface  of  brain,  vertex  and 
base,  and  extending  over  pons  and  medulla.  No  lacera- 
tion ;  contusion  of  inferior  surface  of  left  temporal  and 
frontal  lobes;  general  hyperaemia  and  oedema  of  the  brain. 

Case  CCXXI.  Symptoms.  • —  Patient  fell  during  a 
brawl  and  struck  his  head  upon  the  pavement ;  was  taken 
home  unconscious ;  hemorrhage  from  nose  and  mouth  and 
haematemesis ;  admitted  to  hospital  fifteen  hours  after- 
ward; still  unconscious,  stertor,  general  muscular  rigid- 
ity, dilatation  of  right  pupil,  and  contraction  of  the  left, 
both  irresponsive  to  light;  oedema  of  left  conjunctiva, 
ecchymosis  of  left  eye,  fracture  of  nose,  and  patellar 
reflex  increased.  The  respiration  became  sighing,  the 
patellar  reflexes  were  lost,  and  the  urine  was  retained. 
Two  hours  and  more  after  admission,  respiration  suddenly 
ceased,  the  face  became  cyanotic,  and  the  pulse  was  full, 
regular,  and  bounding.  The  patient  had  an  emission  of 
semen  and  a  gradually  developed  priapism ;  artificial 
respiration  was  continued  four  hours.  When  artificial 
respiration  was   interrupted,   the    abdominal  muscles  be- 


534  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

came  tense,  the  face  cyanotic,  the  pulse  feeble,  and  pria- 
pism subsided;  when  it  was  recommenced,  the  pulse 
again  became  full,  regular,  and  bounding,  priapism  was 
reproduced,  and  cyanosis  disappeared.  Temperature 
from  102°,  on  admission,  rose  progressively  to  106.6°  at 
the  time  artificial  respiration  was  begun,  and  in  ten 
minutes  more  to  107.6°;  it  then  progressively  declined  to 
99.6°  at  death,  with  immediate  post-mortem  recession. 
The  pulse  was  112,  and  the  respiration  34,  on  admission, 
and  were  respectively  170  and  20  when  artificial  respira- 
tion was  commenced;  patient  never  spoke. 

Lesions. — No  fracture;  epidural  clot,  weighing  three 
ounces,  over  left  temporal  and  inferior  parietal,  to  centre 
of  occipital  lobe,  and  from  fissure  of  Sylvius  to  the  base; 
small  limited  contusions  on  the  inferior  surface  of  right 
temporal  lobe,  one  in  the  centre  and  other  on  the  inner 
border;  minute  laceration  of  inferior  surface  of  the  right 
frontal  lobe ;  small  pial  hemorrhage  over  left  fissure  of 
Sylvius :  brain  slightly  cedematous. 

Case  CCXXII.  Symptoms. — Patient  fell  seven  stories 
to  the  ground ;  primary  unconsciousness ;  wounds  with 
subjacent  haematomata  in  left  frontal  region  and  above 
the  ear;  pupils  normal;  lower  limbs  restless.  Patient 
struggled  and  occasionally  groaned  while  the  wounds 
were  being  dressed.  Slight  delirium  and  constant  active 
movements  which  required  mechanical  restraint;  general 
condition  unchanged  till  the  fourth  day,  when  he  became 
quiet  a  few  hours  before  death.  Temperature  on  admis- 
sion was  98°.  and  rose  progressively  to  108°  with  post- 
mortem elevation  to  108.4:  pulse,  70  to  130;  respiration, 
22,  30. 

Lesions. — No  fracture,  no  laceration,  and  only  slight 
pial  hemorrhage,  which  was  upon  left  parietal  lobe;  gen- 
eral hyperaemia  with  punctate  extravasations,  and  oedema 
with  serum  in  the  lateral  ventricles. 

Case  CCXXIII.  Symptoms.— Vq.\:\q.vX  after  a  "boxing 
contest"    walked    to   his   dressing-room  with   much   diffi- 


CASES   VERIFIED   BY   NECROPSY.  535 

culty,  and  suddenly  sank  to  the  floor  unconscious.  He 
had  not  fallen  or  been  knocked  down,  but  had  been  hard 
hit.  On  admission  to  the  hospital,  coma,  stertor,  Cheyne- 
Stokes  respiration,  dilatation  of  right  pupil  with  no  reaction 
to  light,  sluggishness  of  left  pupil,  no  hemorrhages  or  ex- 
ternal injuries,  and  twitching  of  the  left  arm  and  leg, 
which  increased  and  was  followed  by  spasmodic  move- 
ments of  both  sides,  with  the  head  occasionally  carried 
toward  the  left  shoulder.  Trephination  disclosed  sub- 
dural hemorrhage,  and  much  fluid  blood  was  evacuated. 
Tremors  of  the  arms  and  legs  increased  during  the  opera- 
tion, and  afterward  ceased ;  the  respiration  became  regu- 
lar, and  the  pulse  increased  in  frequency;  a  little  later 
there  were  several  general  convulsions;  urinary  control 
was  lost,  and  slight  left  facial  paralysis  was  apparent; 
convulsions  occurred  at  intervals,  the  respiration  became 
again  of  the  Cheyne- Stokes  character,  and  death  occurred 
at  the  end  of  twenty-four  hours.  The  temperature  on  ad- 
mission was  98°,  rose  to  107.2°  after  the  operation  and 
was  reduced  to  103.4°  by  the  ice  pack,  rose  again  in  an 
hour  to  107.2°,  and  remained  persistent  to  that  degree 
except  as  it  was  from  time  to  time  reduced  by  the  ice  ap- 
plication, until  the  last  hours  of  life,  when  it  fell  to  106°. 
The  pulse  was  54  on  admission,  and  after  operation  was 
120  to  140,  and  respiration  30-42.  The  temperature  in- 
creased post  mortem  from  106.2°  to  106.4°. 

Lesions. — No  injuries  of  the  scalp  or  cranium ;  no  epi- 
dural hemorrhage;  slight  pial  hemorrhage  over  the  pos- 
terior part  of  the  hemispheres  and  in  moderately  large 
amount  upon  the  tentorium  and  in  the  posterior  fossae; 
central  laceration  in  the  posterior  part  of  the  left  optic 
thalamus,  five-eighths  by  three-eighths  of  an  inch  in  its 
diameters,  and  mainly  a  disintegration,  not  much  clot; 
general  contusion  of  the  brain  substance,  well-marked 
hypersemia  and  oedema.  The  pial  hemorrhage  was  larger 
upon  the  right  side  and  the  blood  was  fluid.  The  cardiac 
walls  were  moderately  thickened. 


536  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

Case  CCXXIV.  Symptoms. — Patient  fell  down  a  flight 
of  stairs;  on  admission  to  hospital,  semi-conscious  and 
irritable  when  aroused.  Haematoma  of  right  frontal 
region,  and  ecchymosis  of  right  eye;  slight  hemorrhage 
from  nose;  dilatation  of  right  pupil,  which  was  irre- 
sponsive to  light;  no  muscular  symptoms.  He  remained 
in  a  restless,  delirious,  or  stupid  condition  till  his  death 
on  the  seventh  day.  There  was  loss  of  urinary  control  on 
the  fourth  day,  and  coma,  with  picking  at  the  bedclothes 
and  subsultus  tendinum  during  the  last  twenty-four  hours. 
The  temperature,  which  was  98.2°  on  admission,  rose 
slowly  and  progressively  to  102°  on  the  fifth  day,  to  104.2° 
on  the  sixth  day,  and  to  105.2°  one  hour  before  death, 
and  thirty  minutes  post  mortem  to  106.4°.  The  pulse  was 
50-100  for  five  days,  and  afterward  120-130;  the  respira- 
tion was  20-24  for  five  days,  and  then  30-50. 

Lesions. — No  fracture  of  skull,  and  no  epidural  hemor- 
rhage ;  no  superficial  laceration ;  pia  mater  and  cortical 
vessels  very  much  congested ;  some  opacity  of  arachnoid 
membrane,  and  moderate  subarachnoid  effusion ;  no  pial 
hemorrhage;  limited  cortical  contusion,  area  of  one  inch 
in  diameter,  at  bottom  of  left  fissure  of  Sylvius;  lacera- 
tion of  left  optic  thalamus  in  its  central  portion,  at 
junction  of  middle  and  posterior  thirds,  one-fourth  of  an 
inch  in  diameter  and  filled  with  clot.  Subcortical  lacera- 
tions of  the  left  side  of  the  pons,  one-third  of  an  inch  in 
diameter,  in  the  transverse  fibres;  a  few  punctate  extra- 
vasations in  different  parts  of  the  brain ;  general  hyper- 
aemia,  and  well-marked  oedema. 

Case  CCXXV.  Symptoms.  —  Primary  and  permanent 
unconsciousness  following  a  fall  of  twelve  feet ;  on  arrival 
of  ambulance,  pupils  normal,  and  left  radial  pulse  fuller 
and  stronger  than  the  right.  On  admission  to  hos- 
pital, haematoma  in  right  parietal  region;  temperature, 
97.4°;  pulse,  70;  respiration,  28;  left  hemiplegia,  and  loss 
of  faecal  and  urinary  control;  incision  of  haematoma  dis- 
closed no  fracture.     Teniperature  in  six  hours,  97.6°;  in 


CASES    UNVERIFIED    BY    NECROPSY.  537 

eight  hours,  99°;  in  ten  hours,  99.4°;  and  in  thirteen 
hours,  109''.  Death  occurred  fifteen  minutes  later,  and 
temperature  one  hour  post  mortem  was  109.4=;  pulse, 
74-150;  respiration,  30-60. 

Lesions, — No  fracture ;  no  epidural  hemorrhage;  lacer- 
ation of  right  parieto-occipital  region,  and  large  cortical 
hemorrhage  covering  the  whole  vertex ;  excessive  general 
cerebral  hypersemia  and  oedema. 


II. 

CASES  UNVERIFIED  BY  NECROPSY. 

Case  CCXXVI. — Male,  aged  forty  years,  fell  down  five 
steps  of  a  stairway ;  had  hemorrhage  from  the  right  ear, 
but  walked  home ;  two  convulsions  next  day,  and  patient 
then  taken  to  hospital,  stupid,  muttering,  and  with  con- 
tinued hemorrhage  from  the  ear.  Two  other  convulsions 
followed,  most  marked  upon  the  right  side.  On  the  third 
day  he  remained  in  a  stupid  condition,  incoherent,  and 
irrational,  getting  out  of  bed  to  urinate  and  using  another 
patient's  shoe  or  the  floor  of  the  ward  indifferently,  and 
was  transferred  from  St.  Vincent's  to  Bellevue  Hospital. 
The  temperature  on  admission  to  St.  Vincent's  was  101.2° 
and  declined  to  100.6°,  with  a  pulse  of  60.  He  became 
violently  delirious  at  Bellevue  two  days  later,  and  after- 
ward his  mental  condition  was  normal.  It  was  said  by  his 
family  that  he  had  not  been  drinking  at  the  time  of  the 
accident. 

Case  CCXXVII. — Male,  aged  twenty-two  years,  fell 
three  stories ;  primary  loss  of  consciousness ;  contusions  of 
right  side  of  head  and  face,  hemorrhage  from  right  ear 
and  mouth ;  pulse  full,  sIoav,  and  sixty  per  minute ;  breath- 
ing labored,  and  pupils  normal ;  consciousness  regained 
on  the  sixth  day;  patient  restless,  and  when  disturbed 
irritable  from  the  first  day.  During  the  second  week, 
mental    condition  variable  and   articulation  somewhat  in- 


538  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

distinct.  In  the  third  week,  the  temperature  became 
normal,  the  mind  clear,  and  a  swelling  of  the  left  side  of 
the  face  which  had  been  observed  from  time  of  admission 
to  the  hospital  increased  and  later  disappeared;  right 
lower  facial  paralysis  became  evident.  In  the  fourth 
week,  articulation  was  again  indistinct,  and  the  mental 
condition  weak.  The  patient  when  asked  about  the 
manner  of  his  injury  talked  of  taking  a  basket  of  clams 
from  Koster  and  Bial's,  whom  he  called  "  Kosher  and  Beel" 
or  "Kosher  and  Clams";  his  laugh  was  silly,  his  manner 
indicated  dementia,  and  he  had  delusions.  In  the  fifth 
week  his  mind  suddenly  became  clear,  he  conversed 
rationally,  and  he  remembered  all  the  circumstances  at- 
tending his  accident.  At  this  time  he  was  removed  from 
the  hospital.  The  temperature  became  normal  on  the 
fifth  day  and  did  not  afterward  exceed  99°;  it  was  oftener 
98°. 

Case  CCXXVIII.— Male,  aged  thirty  years,  fell  from 
elevated  railway  track,  striking  upon  left  side  of  his  head 
and  face;  slight  hemorrhage  from  right  ear;  conscious- 
ness not  wholly  lost ;  pulse  and  respiration  slow.  On  the 
following  day  he  sufficiently  recovered  consciousness  to 
discover  loss  of  vision  in  the  left  eye ;  he  responded  slowly 
to  questions,  and  was  somnolent.  Examination  of  the  eye 
made  by  Dr.  Callan  on  the  fourth  day:  Left  pupil  not 
responsive  to  light  on  direct  exposure,  but  contracted  with 
its  fellow  when  both  were  simultaneously  exposed ;  retinal 
examination  negative;  optic  nerve  believed  to  be  impli- 
cated in  a  fracture  passing  through  optic  foramen.  Ninth 
day,  pain  in  the  head  behind  the  right  ear  and  above  the 
left  eye,  and  incomplete  left  facial  paralysis  involving  the 
tongue.  Sixteenth  day,  sero-sanguinolent  discharge  from 
both  ears  since  the  tenth  day;  mind  clearer,  with  loss  of 
memory;  commencing  atrophy  of  the  left  optic  nerve. 
The  discharge  from  the  ears  ceased  on  the  eighteenth 
day.  The  temperature  on  admission  was  99°,  immediately 
rose  to  100°,  and  afterward  ranged  from  98°  to  99°, 


CASES    UNVERIFIED    BY    NECROPSY.  539 

The  patient,  a  man  of  unusual  intelligence,  said  when 
discharged  from  the  hospital  at  the  end  of  the  second 
month  that  in  the  sixth  week  he  began  to  recollect  the 
circumstances  which  had  attended  his  accident,  and  that 
since  then  the  mental  confusion  from  which  he  suffered 
had  gradually  disappeared. 

Case  CCXXIX. — Male,  aged  thirty  years,  struck  by  a 
falling  ladder;  hemorrhage  from  mouth  and  nose,  and 
blood  and  brain  matter  exuded  from  right  ear ;  both  eyes 
protruded,  and  both  pupils  were  contracted  and  irrespon- 
sive to  light;  right  facial  paralysis;  respiration  stridulous. 
Right  pupil  soon  began  to  dilate  slowly.  Temperature, 
100°;  pulse,  93;  patient  remained  unconscious  till  death 
two  hours  after  injury. 

Case  CCXXX.  —  Male,  aged  twenty-three  years, 
walked  out  of  a  window  while  sleeping  and  fell  three 
stories  to  a  stone  pavement  below,  striking  an  iron  fence 
on  the  way.  He  remained  unconscious  from  fifteen  to 
twenty  minutes.  On  admission  to  hospital,  a  very  pro- 
fuse serous  discharge  began  from  the  right  ear  and 
continued  for  several  days.  Pupils  and  respiration 
normal;  severe  vertigo,  aggravated  on  attempting  to  arise 
or  on  opening  his  eyes ;  several  attacks  of  vomiting ;  tem- 
perature, 99° ;  pulse,  90.  On  the  fourth  day  he  had  in- 
complete upper  and  lower  facial  paralysis,  which  continued 
for  a  week's  time.  On  the  eighth  day  he  had  three  gen- 
eral convulsions,  and  one  on  the  next  day.  On  the  twen- 
tieth day  he  began  to  have  severe  pain  in  the  right  ear, 
and  as  later  the  mastoid  region  became  swollen  and  in- 
flamed it  was  trephined  for  exploration,  with  negative 
result.  The  temperature  but  once  exceeded  99°.  The 
mastoid  inflammation  disappeared  at  once  after  trephina- 
tion.    Recovery  was  complete. 

Case  CCXXXI. — Female,  aged  forty-seven,  fell  on  the 
street  in  a  convulsion  during  a  debauch ;  had  other  con- 
vulsions before  admission  to  hospital;  left  side  of  head  and 
eyelid  much  contused ;  mental  condition  stupid ;  pupils  nor- 


540  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

mal;  breathing  stertorous;  pulse,  io8;  convulsions  con- 
tinued during  the  day  and  night ;  no  interval  of  conscious- 
ness. During  the  morning  a  severe  hemorrhage  occurred 
from  the  mouth  without  previous  warning.  In  the  afternoon 
pulse  and  respiration  became  frequent.  The  blood  which 
came  from  the  mouth  was  bright  in  color,  non-aerated, 
and  said  to  be  more  than  eight  ounces  in  amount.  The 
next  day  the  convulsions  were  diminished  in  frequency 
and  were  general,  but  more  severe  in  the  right  arm.  No 
initial  symptom  noted.  Both  arms  were  rigid  and  head 
constantly  turned  to  the  right.  There  were  in  all  twenty- 
three  convulsions.  Death  occurred  in  thirty-eight  hours. 
Temperature,  one  hour  after  admission,  102.4°;  morning 
of  next  day,  105.6°;  later,  107.4°,  106.2°,  107.8° — the  last 
observation  one  hour  before  death. 

Case  CCXXXIL— Male,  aged  twenty-four,  fell  down 
stairs ;  wound  over  right  eye ;  hemorrhage  from  right 
nostril,  coma,  stertor,  pupils  contracted;  temperature, 
98.5°;  pulse,  120;  no  paralysis  or  muscular  rigidity; 
reflexes  normal ;  fracture  of  left  thigh.  Clonic  spasm  of 
left  side  five  hours  after  admission.  Death  in  ten  hours 
after  reception  of  injury.  Hourly  temperature,  100°,  101°, 
102.4°,  102.4°,  103°,  104.4°,  105°,  106.4°.  Thirty  minutes 
post  mortem,  108.8°. 

Case  CCXXXIIL— Male,  aged  sixty,  knocked  down 
by  a  truck ;  scalp  wound  in  right  posterior  occipital 
region.  A  linear  fracture  running  backward  and  down- 
ward was  discovered  by  incision.  Patient  unconscious 
and  restless.  Pupils  contracted;  pulse,  66;  very  slight 
movements  of  right  side  of  body;  no  facial  paralysis; 
speech  only  in  monosyllables.  In  a  short  time  right  hemi- 
plegia became  complete,  pulse  weaker,  temperature  lower, 
and  there  was  a  slight  general  convulsion  lasting  about 
ten  seconds.  Four  hours  later,  coma  was  profound,  pupils 
small  and  irresponsive,  pulse  and  respiration  very  irregu- 
lar, and  restlessness  ceased.  The  patient  was  trephined 
over  left  motor  area.     The  fissure  was  found  to  extend 


CASES   UNVERIFIED    BY   NECROPSY.  54I 

downward  behind  the  mastoid.  Epidural  hemorrhage  was 
disclosed,  and,  after  incision  of  dura,  subdural  hemor- 
rhage. He  died  three  hours  later,  and  eleven  hours  after 
reception  of  injury. 

Case  CCXXXIV. — Male,  aged  forty  years;  cause  of 
injury  unknown;  contusions  behind  both  ears;  free  hem- 
orrhage from  right  ear,  and  during  the  night  from  both 
ears  and  mouth ;  pupils  contracted ;  pulse  full  and  slow ; 
breathing  labored;  temperature,  99.2°;  became  105°.  He 
did  not  regain  consciousness,  and  died  six  hours  after 
admission. 

Case  CCXXXV.— Male,  aged  twenty  years;  fell  thir- 
teen feet ;  large  haematoma  in  left  posterior  parietal  region ; 
unconscious ;  oozing  from  left  ear  and  nose ;  pupils  con- 
tracted, and  eyes  turned  persistently  to  the  right;  mouth 
drawn  slightly  to  the  right ;  breathing  irregular ;  vomiting 
free ;  extremities  cold  and  muscles  relaxed ;  urine  incon- 
tinent; temperature,  99.5°.  Soon  after  admission  hemor- 
rhage from  nose  ceased,  but  continued  from  ear.  Pa- 
tient could  be  roused  partially  but  with  difficulty,  became 
restless,  and  moved  his  right  side  rather  less  freely  than 
the  left.  Temperature,  10 1^.  Two  hours  after  admission 
to  the  hospital  breathing  became  stertorous  and  tonic 
spasms,  beginning  in  the  right  arm,  became  general. 
Two  attacks  of  opisthotonos  followed,  and  ceased  after 
thirty  minutes.  Left  pupil  became  the  larger,  while  the 
right  eye  still  turned  to  the  right  on  exposure.  Tempera- 
ture, 105°;  pulse,  96;  respiration,  32,  and  of  the  Cheyne- 
Stokes  variety.  An  hour  later,  coma  was  profound,  with 
slow  and  stertorous  respiration.  Temperature,  106.6°. 
Respiration  became  insufficient,  four  to  the  minute,  and 
face  cyanotic.  Death  occurred  in  four  hours.  Pupils  post 
mortem  were  widely  dilated. 

Case  CCXXXVI. — Male,  aged  forty  years,  fell  two 
stories  and  struck  his  head  upon  the  pavement ;  no  loss  of 
consciousness,  but  primary  delirium ;  wound  in  the  left 
temporal    region ;    hemorrhage    from    mouth    and    nose ; 


542  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

normal  pupils.  The  delirium,  which  continued  four  days, 
was  succeeded  by  indications  of  mental  disorder;  confu- 
sion of  ideas,  loss  of  memory,  delusions,  and  at  a  later 
period  slowness  of  comprehension.  The  patient  at  the 
time  of  his  discharge  from  the  hospital,  in  the  second 
month,  when  questioned,  would  long  remain  buried  in 
thought,  and  his  answer  when  made  would  be  slow  and 
halting  though  coherent.  He  never  had  knowledge  of  the 
manner  of  his  injury,  and  only  at  the  last  recognized  his 
surroundings.  There  were  no  other  than  mental  symp- 
toms after  the  first  week.  On  the  second  day,  the  surface 
of  the  right  side,  which  was  in  much  more  active  motion 
than  th3  left,  was  warm,  while  that  of  the  left  was  cold, 
and  the  right  axillary  temperature  was  0.6°  higher  than 
the  left.  There  was  also  dysphagia.  On  the  third  day, 
there  was  post-cervical  rigidity;  and  on  the  third  and 
fourth  days  lack  of  fsecal  and  urinar}^  control.  The  tem- 
perature only  once  exceeded  ioo°-|-,  and  was  then  102.2°. 
The  right  axillary  temperature  was  0.4°  to  0.6°  higher 
than  the  left  during  the  first  week,  and  at  a  later  period 
the  left  was  usually  0.2°  higher  than  the  right,  but  not  with 
uniformity.  The  pulse  was  66-98,  and  the  respiration 
20-26. 

Case  CCXXXVII. — Female,  aged  thirty  years,  was 
struck  upon  the  head  by  a  piece  of  board  which  had  fallen 
thirty  feet;  primary  unconsciousness;  compound  fracture 
of  right  parietal  bone  in  its  anterior  and  superior  portion ; 
trephination ;  longitudinal  sinus  had  been  wounded  by  an 
osseous  fragment.  Examination  made  fourteen  months 
later:  Loss  of  bone  substance  in  an  area  one  and  one- 
fourth  inches  by  three-fourths  of  an  inch,  just  to  the  right 
of  the  median  line  at  the  fronto-parietal  junction ;  open 
fissure  felt  through  the  skin  extending  from  this  point 
through  the  median  line  into  the  right  orbital  plate;  loss 
of  sense  of  smell,  and  deficient  sense  of  taste,  on  the  right 
side. 

Case  CCXXXVIII.— Male,  aged  forty  years,  fell  from 


CASES   UNVERIFIED    BY   NECROPSY.  543 

a  truck  and  struck  upon  his  head;  partial  loss  of  conscious- 
ness ;  profuse  hemorrhage  from  right  ear ;  wide  dilatation 
of  left  pupil;  temperature,  99.8°;  pulse,  92;  and  respira- 
tion, 23.  Second  day,  slight  delirium,  mental  stupor,  no 
response  to  questions;  temperature,  100.8°.  Third  day, 
severe  general  convulsion,  beginning  in  left  arm  and 
hand  ;  both  pupils  afterward  widely  dilated  ;  temperature, 
100.2°  to  100.6°,  Fourth  day,  similar  convulsion,  but  less 
severe;  temperature,  99.8°  to  100°.  Eighth  day,  mind 
clear,  but  torpid ;  no  recollection  of  an  accident  having 
occurred;  speech  slow  and  somewhat  aphasic;  headache 
and  continued  dilatation  of  pupils.  Twelfth  day,  mental 
condition  normal;  temperature,  99°+.  Discharged  with- 
out further  symptoms  on  the  twenty-ninth  day. 

Case  CCXXXIX.— Male,  aged  fifty-five  years,  fell  un- 
conscious in  the  street.  On  admission,  profound  shock 
and  entire  unconsciousness;  wound  of  scalp  in  right  pos- 
terior parietal  region ;  free  hemorrhage  from  right  ear 
and  uniform  contraction  of  pupils  One  hour  later,  rigid- 
ity of  left  arm  and,  to  a  less  extent,  of  left  leg.  Con- 
sciousness restored  in  twenty-four  hours,  and  a  little  later 
the  pupils  became  normal  and  the  mind  clear.  Tempera- 
ture on  admission,  98°,  declined  to  97.4°,  and  rose  in 
twenty-four  hours  to  99.4° ;  pulse  and  respiration  normal. 
On  the  third  day,  temperature,  99.6°,  and  only  psychic 
symptoms;  mental  processes  a  little  less  slow  than  on  the 
previous  day,  but  memory  defective.  No  recollection  of 
anything  which  happened  after  leaving  home  in  the  early 
morning,  some  hours  pevious  to  the  accident ;  memory  of 
words  and  facts  equally  deficient.  Upon  questioning,  the 
patient  said  that  he  lived  at  "No.  4  in  the  Ninth  Ward;" 
then  remembered  that  it  was  opposite  a  school,  which  he 
called  "skull,"  and  finally  that  it  was  in  Grove  Street. 
On  the  following  day  he  had  again  forgotten  the  name  of 
the  street,  and  its  mention  awakened  no  remembrance ;  he 
misplaced  many  words,  and  could  not  be  brought  to  recog- 
nize his  errors.     A  week  later  he  had  much  general  head- 


544  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

ache,  realized  that  his  mind  had  been  greatly  confused, 
and  was  still  ignorant  of  all  that  had  happened  since  leav- 
ing his  house.  He  was  discharged  on  the  eighteenth  day, 
his  temperature  and  mental  condition  having  been  normal 
for  several  days. 

Case  CCXL. — Male,  aged  forty-five  years,  thrown 
from  a  truck  in  collision ;  admitted  to  hospital  in  shock  and 
still  unconscious;  pupils  contracted;  temperature,  97.5°; 
pulse,  52;  respiration,  18;  twelve  hours  later,  temperature, 
97.5°;  pulse,  50;  respiration,  12;  in  fourteen  hours  con- 
sciousness restored ;  temperature,  98°.  Second  day,  no 
recollection  of  injury,  previous  occupation,  or  married  con- 
dition. Third  day,  ecchymosis  over  right  mastoid  process 
an-d  extending  upon  the  back  of  the  ear,  not  previously 
apparent.  Fourth  day,  the  patient,  after  much  question- 
ing and  trouble,  was  enabled  to  remember  his  residence 
and  occupation;  temperature,  102°.  During  the  rest  of 
the  week  his  temperature  declined  and  mental  condition 
improved,  though  he  was  still  irrational  and  at  night  re- 
quired mechanical  restraint.  In  the  second  week  he  was 
rational  at  times;  he  was  capable  of  expressing  the  gen- 
eralization that  a  man's  mind  is  clearer  by  day  than  at 
night,  and  described  correctly  the  manner  in  which  he 
received  his  hurt,  though  he  again  forgot  the  circum- 
stances and  denied  that  he  had  said  anything  about  it; 
he  was  irritable  and  forgetful,  even  of  the  outrage  to 
which  he  considered  himself  subjected  in  the  taking  of  his 
temperatures;  he  had  delusions,  saw  imaginary  persons, 
and  heard  unreal  voices,  made  contradictory  statements 
about  the  injury  which  he  had  suffered,  and  was  much  an- 
noyed at  the  attempts  which  were  made  to  get  from  him 
some  coherent  and  consistent  history.  Early  in  the  third 
week  his  temperature  became  normal,  his  memory  and 
other  mental  faculties  were  restored,  and  he  was  dis- 
charged from  the  hospital. 

Case  CCXLI.  —  Male,  aged  forty-five  years,  mind  im- 
paired by  alcoholic  excess,  fell  one  flight  of  stairs;  con- 


CASES    UNVERIFIED    BY   NECROPSY.  545 

sciousness  retained,  hsematoma  in  left  temporal  region, 
profuse  hemorrhage  from  left  ear,  and  slight  epistaxis. 
Temperature,  98"^;  pulse,  90;  respiration,  24.  Second 
day,  a  little  delirium,  rigidity  of  both  arms,  and  left  facial 
paralysis  both  upper  and  lower;  temperature,  100.2°; 
pulse,  100 ;  respiration,  24.  Incision  made  through 
haematoma  revealed  linear  fracture  of  left  squamous  por- 
tion extending  into  the  base.  In  the  three  days  follow- 
ing, the  temperature  and  mental  condition  became  normal 
and  facial  paralysis  nearly  disappeared.  Two  days  later 
temperature  rose  to  100.5°,  facial  paralysis  increased,  left 
side  of  face  and  neck  became  swollen,  and  delirium  super- 
vened. From  this  time  there  were  recurrent  maniacal 
attacks,  lasting  less  than  twenty-four  hours,  in  one  of 
which  he  was  transferred  to  Bellevue  Hospital  and  soon 
afterward  escaped.  He  was  at  a  subsequent  period  sent 
to  an  asylum  for  the  insane,  and  sixteen  months  later  was 
still  of  unsound  mind. 

Case  CCXLII. — Male,  aged  thirty-five  years,  fell  one 
story ;  brief  unconsciouness  followed  at  once  by  delirium ; 
extensive  lacerated  wound  in  left  parietal  region ;  hemor- 
rhage from  left  ear  caused  by  wounds  of  external  meatus. 
Temperature  on  admission  to  hospital,  101.5°;  pulse,  80; 
respiration,  18.  Delirium  continued  three  weeks,  gradually 
diminishing  in  degree  and  constancy;  no  subsequent  rec- 
ollection of  the  manner  of  injury.  Loss  of  urinary  control 
lasted  one  week ;  no  headache  at  any  time,  and  no  later 
symptoms.  Patient  recognized  his  family  and  surround- 
ings after  three  or  four  days. 

Case  CCXLIII. — Female,  aged  five  years,  struck  by 
a  falling  box  which  seemed  to  have  crushed  her  head  la- 
terally against  the  floor.  Still  unconscious  at  time  of  admis- 
sion to  hospital,  but  very  sensitive  to  external  irritations ; 
slight  twitching  of  right  side  of  the  face,  slight  epistaxis, 
slightly  accelerated  respiration,  slow  and  irregular  pulse; 
temperature,  95°;  pupils  sometimes  normal,  sometimes 
widely  dilated,  with  conjugate  deviation  which  was  some- 
35 


546  INJURIES   OF   THE   BRAIN   AND    MEMBRANES. 

times  upward  and  sometimes  to  the  left;  vomiting  soon 
after  reception  of  the  injury ;  haematoma  over  entire  ver- 
tex, and  contusion  of  both  eyes.  Incision  disclosed  fis- 
sures on  either  side  of  the  calvarium ;  one  extended  from 
the  left  temporal  fossa  posteriorly  across  the  vertex  to  the 
right  occiptal  region,  and  anteriorly  into  the  anterior 
fossa ;  another,  apparently  beginning  in  the  right  anterior 
fossa,  crossed  the  right  parietal  bone  and  terminated  in 
the  first.  The  bone  was  depressed  posteriorly  and  the  fis- 
sures were  open ;  after  elevation  and  removal  of  some 
small  fragments  considerable  epidural  hemorrhage  was  ap- 
parent. Consciousness  was  fully  restored  within  twenty- 
four  hours,  and  was  marked  by  restlessness  and  delirium, 
which  continued  for  two  or  three  days,  after  which  the 
mental  condition  was  normal.  On  the  fifth  day  paraplegia 
occurred,  which  was  almost  complete  from  the  first,  and 
absolute  on  the  next  day,  with  partial  anaesthesia;  no 
paralysis  of  the  bladder  or  rectum.  The  paraplegic  con- 
dition began  to  improve  at  the  end  of  a  week's  time,  but 
very  slowly ;  a  few  steps  could  be  taken  without  assistance 
six  weeks  later.  The  temperature  soon  after  admission 
rose  from  95°  to  98.5°,  on  the  next  day  to  100.2°,  and  after 
the  third  day  varied  from  98.4°  to  99.8°;  usually  normal 
in  the  morning.  The  respiration  was  accelerated  for  the 
first  ten  days,  and  the  pulse  frequent  for  three  days. 

Case  CCXLIV.  —  Female,  aged  thirty  years ;  was 
thrown  from  a  wagon  while  driving,  striking  the  back  of 
her  head  upon  an  asphalt  pavement;  shock,  loss  of  con- 
sciousness for  twenty  minutes,  and  severe  vomiting, 
which  persisted  during  the  day;  temperature,  100°;  not 
taken  afterward;  haematoma  in  right  occipital  region,  and 
ecchymosis  behind  the  right  ear,  followed  by  severe  local- 
ized pain  in  the  right  side  of  the  head  posteriorly.  The 
later  symptoms  were  a  mufiled  feeling  in  the  right  ear, 
with  diminished  hearing  and  blunted  perceptions  of  taste 
and  smell  which  had  been  noted  from  the  time  of  the  acci- 
dent.     The  disorders  of  hearing  did  not  continue  after 


CASES    UNVERIFIED    BY   NECROPSY.  547 

the  fourth  week,  but  the  senses  of  taste  and  smell  have 
been  permanently  impaired. 

Case  CCXLV.  —  Male,  aged  thirty-six  years;  fell  ten 
feet  from  a  vessel  to  a  raft  alongside  and  then  into  the 
water;  brief  period  of  unconsciousness,  profuse  hemor- 
rhage from  left  ear,  slight  epistaxis  from  left  nostril,  and 
haematoma  in  left  mastoid  region ;  single  general  convul- 
sion in  the  ambulance  followed  by  stertor;  consciousness 
regained  at  time  of  admission;  both  pupils  widely  dilated; 
hemorrhage  from  the  ear  recurred  during  the  night;  urine 
retained;  temperature,  98.8°.  Frontal  headache  con- 
tinued for  several  days,  and  on  the  third  day  there  was 
transient  photophobia  with  contracted  pupils.  The 
bladder  and  rectum  were  controlled.  Dilatation  of  the 
pupils  was  perceptible  till  the  end  of  the  second  week  and 
of  the  right  pupil  even  longer.  The  prominent  symptoms 
were  mental ;  nocturnal  restlessness  and  delirium,  and  a 
rather  stupid  condition  during  the  day,  were  succeeded  in 
the  second  week  by  continued  delirium  of  a  mild  type 
with  delusions.  In  the  third  week  active  delirium 
ceased,  though  restlessness  at  night  persisted ;  the  facial 
expression  was  more  intelligent  and  speech  was  coherent ; 
there  was  perfect  recollection  of  the  m.anner  in  which  the 
injury  had  been  received,  and  also  of  a  similar  accident 
which  had  occurred  on  the  same  day  and  aboard  the  same 
ship,  but  delusions  were  numerous  and  constant.  At  the 
beginning  of  the  fourth  week  the  patient  was  restless,  ex- 
citable, talkative,  and  had  again  forgotten  the  manner 
and  even  fact  of 'his  injury.  Ophthalmic  examination  was 
made  by  Dr.  Callan  with  negative  result.  At  the  end  of 
the  fourth  week  delusions  finally  ceased,  and  when  dis- 
charged from  the  hospital  in  the  eighth  week  there  were 
no  symptoms  remaining.  The  sense  of  smell  was  entirely 
lost. 

The  maximum  temperature  was  on  the  fourteenth  day, 
from  101°  to  102.2°;  the  usual  temperature  was  99°+  till 
after  the  fourth  week,  and  then   varied  from  normal  to 


548  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

99°.  The  axillary  temperatures  were  observed  from  the 
fourth  to  the  eighth  weeks;  the  left  was  habitually,  but 
irregularly,  higher  than  the  right.  The  pulse  and  respi- 
ration presented  no  notable  changes. 

Case  CCXLVI.  —  Female,  aged  seventeen  years,  fell 
from  second-floor  window;  found  in  coma  with  profuse 
hemorrhage  from  left  ear  and  some  hemorrhage  from  the 
mouth;  left  side  of  face,  eye,  and  parietal  region  much 
contused.  Two  hours  later  consciousness  was  partially 
restored  and  sensitiveness  to  external  impressions  recov- 
ered; hsematemesis  occurred,  and  at  a  later  period,  after 
subsidence  of  ecchymosis  of  the  lids,  subconjunctival  hem- 
orrhage in  the  left  eye  was  discovered;  the  right  pupil 
was  dilated.  Six  hours  after  admission  to  hospital,  tem- 
perature, 97.4°;  pulse,  70;  respiration,  38;  lack  of  urinary 
control.  The  hemorrhage  from  the  left  ear  continued  for 
thirty-six  hours,  and  was  followed  by  a  discharge  of 
bloody  serum.  During  the  first  three  or  four  days  the 
patient  was  at  times  noisy  and  restless  and  at  times  quiet. 
She  then  became  rational  and  learned  for  the  first  time 
that  she  had  met  with  an  accident  and  was  in  a  hospital ; 
but  she  never  knew,  then  or  afterward,  of  her  own  recol- 
lection what  had  happened  to  her.  At  about  the  same 
time  a  protrusion  of  the  left  eye  became  marked,  and  it 
was  discovered  that  vision  was  lost  on  that  side.  There 
were  no  additional  symptoms.  The  temperature  on  the 
second  day  was  100.2°;  pulse,  68;  respiration,  18;  and 
temperature  afterward  varied  from  99°  to  ioo°-|-. 

At  the  end  of  the  fourth  week  ophthalmic  examination 
was  made  by  Dr.  Callan.  The  right  eye  was  in  all 
respects  normal.  The  left  eye  was  on  a  slightly  anterior 
plane  to  that  of  the  right ;  its  movements  were  unim- 
paired; there  was  a  slight  remaining  trace  of  hemorrhage 
near  the  limbus  corneae ;  the  pupil  was  moderately  dilated 
and  not  responsive  to  direct  rays  of  light,  but  acted  con- 
sensually  with  the  right;  there  was  commencing  atrophy 
of  the  optic  nerve  and  total  loss   of   vision.     From    the 


CASES    UNVERIFIED    BY   NECROPSY.  '     549 

clinical  history  Dr.  Callan  was  of  opinion  that  a  line  of 
fracture  had  implicated  the  left  optic  foramen. 

Case  CCXLVII. — Male,  aged  forty  years,  found  in 
the  street  in  an  alcoholic  condition ;  could  walk  with  assist- 
ance; profuse  hemorrhage  from  left  ear;  slight  oedema  of 
scalp  in  left  occipital  region ;  no  general  symptoms.  The 
recollection  of  having  been  brought  to  the  hospital  and 
of  previous  wanderings,  but  not  of  the  manner  of  injury, 
returned  with  sobriety.  Ecchymosis  of  both  lids  of  right 
eye  appeared  on  the  following  day ;  vertigo  and  occipital 
headache  and  some  pain  behind  the  left  ear  existed  for 
ten  da3's.  Temperature  on  admission,  98.4°;  rose  to  101° 
in  the  course  of  eighteen  hours,  and  was  afterward  99°  to 
ioo'^-["  during  the  three  weeks  the  patient  remained  under 
observation.  The  axillary  temperatures  were  usually 
symmetrical,  and  when  any  difference  was  noted  it  was 
higher  on  the  left  side.  The  pulse  more  frequently  ex- 
ceeded 90  or  100  than  is  usual  in  similar  cases.  The 
respiration  was  normal. 

Case  CCXLVIIL— Male,  aged  fifty  years,  fell  twelve  to 
fifteen  feet  from  a  loft  and  struck  upon  the  back  of  his  head, 
six  hours  previous  to  admission  to  hospital ;  unconscious 
fifteen  minutes ;  contusion  of  the  vertex  in  the  median  line ; 
wound  in  right  occipito-mastoid  region ;  hemorrhage  from 
right  ear;  delirium  from  time  consciousness  was  restored, 
often  requiring  mechanical  restraint;  dilated  pupils,  and 
right  radial  pulse  fuller  and  stronger  than  the  left;  the 
urine  was  retained  and  the  right  hand  and  wrist  were  par- 
etic. There  was  marked  aphasia — e.g.,  the  patient  said 
"talpthat"  for  stop  that,  "guth  Got"  for  good  God,  and 
"15  Avenue  B"  when  asked  his  name.  The  difference  in 
the  fulness  and  strength  of  the  radial  pulses  continued  to 
be  strongly  marked  at  all  times  till  death  on  the  eighteenth 
day.  The  dilatation  of  the  pupils,  which  remained  sensi- 
tive till  the  seventeenth  day,  was  also  permanent.  Delir- 
ium persisted,  and  speech  was  infrequent  and  unintel- 
ligible till  the  close  of  the  first  week ;  the  mental  condition 


550  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

then  became  brighter  and  speech  distinct  and  coherent, 
but  delusions  were  constant  and  the  patient  was  at  no 
time  able  to  recognize  his  family  or  friends.  There  were 
subsequent  alternations  of  restlessness  and  excitability 
with  somnolence  or  lethargy,  but  no  cessation  of  delirium, 
delusions,  and  more  or  less  incoherent  and  unintelligible 
speech,  till  final  unconsciousness,  which  occurred  three 
days  before  death.  Sensitiveness  to  external  irritations 
was  marked  throughout  this  later  stage.  The  control  of 
urine  and  faeces  was  permanently  lost  during  the  first  few 
days.  The  paresis  of  the  right  hand  was  much  diminished 
during  the  first  week.  On  the  sixth  day,  and  on  the 
seventh,  there  was  a  short,  severe,  convulsive  attack,  fol- 
lowed by  a  transient  high  temperature.  These  were  suc- 
ceeded on  the  morning  of  the  eleventh  day  by  a  general 
convulsion,  which  was  at  first  confined  to  the  upper  ex- 
tremities, and  continued  twenty  minutes ;  the  right  arm 
was  less  rigid  than  the  left.  Another  attack  in  the  after- 
noon of  the  same  day,  of  twenty-five  minutes'  duration, 
began  with  a  twitching  of  the  facial  muscles,  and  was  ex- 
tended to  the  trunk ;  all  the  extremities  remained  rigid ; 
the  face  was  of  a  natural  color,  though  subsequently  much 
flushed,  but  the  hands  were  blue.  The  morning  convul- 
sion was  followed  by  prolonged  unconsciousness,  that  of 
the  afternoon  by  an  apparently  natural  sleep  after  a  short 
interval  in  which  the  mind  was  unusually  clear  and  alert. 
There  was  another  very  brief  general  convulsion  five  days 
later.  Posterior  cervical  muscular  rigidity  existed  from 
the  ninth  to  the  fourteenth  days.  The  temperature  on 
admission  was  ioi.8°,  and  varied  from  ioo°-|-  to  ioi°-l-  till 
the  fourth  day,  when,  without  other  change  in  symptoms, 
it  rose  to  104°,  and  in  the  twelve  hours  following  de- 
clined to  ioi°-|-,  and  was  continuous  at  about  that  degree 
till  the  tenth  day,  except  at  the  time  of  the  first  and 
second  convulsive  attacks,  when  it  rose  for  a  short  time  to 
106°  and  106.6°;  on  the  morning  of  the  tenth  day  it  rose 
to  105°,  again  declined  to  101°,  and  with  the  occurrence  of 


CASES    UNVERIFIED   BY   NECROPSY.  55 1 

the  third  and  fourth  paroxysms  on  the  eleventh  day  it 
rose  to  105.4°;  on  the  twelfth  day  it  declined  for  a  brief 
interval  to  normal,  and  was  subsequently  uniformly  high 
from  103°  to  106°,  and  at  death  was  108°.  In  fifty-two 
observations  the  right  axillary  temperature  was  higher 
than  the  left  in  thirty-two,  the  left  higher  than  the  right 
in  seven,  and  in  thirteen  the  two  were  uniform ;  the  vari- 
ation was  from  two-tenths  of  a  degree  to  a  degree  and 
eight-tenths.  The  pulse  on  admission  was  112,  and  then, 
for  the  first  ten  days,  65  to  100;  never  afterward  below 
120.  The  respiration  on  admission  was  36,  and  after  the 
first  four  days  rarely  below  32. 

Case  CCXLIX. — Male,  aged  thirty-eight  years,  ad- 
mitted to  hospital  in  an  alcoholic  condition  without  a  his- 
tory ;  profuse  hemorrhage  from  the  left  ear.  The  patient 
never  afterward  remembered  having  been  hurt.  During- 
the  first  week  hearing  was  greatly  impaired  in  both  ears, 
and  there  was  much  mental  confusion,  with  sensory  aphasia 
and  general  loss  of  memory.  General  headache  was 
severe  and  vertigo  marked.  The  patient  was  enabled  to 
recollect  with  great  difficulty  the  place  of  his  employment, 
and  could  only  suggest  his  occupation  as  a  waiter  by  using 
an  imaginary  corkscrew  in  dumb  show.  The  right  radial 
pulse  on  the  second  day  was  fuller  and  stronger  than  the 
left.  In  the  second  week  hearing  was  quite  restored  in 
the  right  ear  and  was  nearly  recovered  in  the  left.  The 
mental  condition  became  normal,  and  there  were  no 
further  symptoms.  The  temperature  on  admission  was 
99.2°,  and  did  not  subsequently  exceed  ioo°-f-.  The  left 
axillary  temperature  was  two-tenths  of  a  degree  higher 
than  the  right  when  there  was  a  lack  of  symmetry.  The 
pulse  on  admission  was  80,  and  was  only  once  above  100. 
The  respiration  w^as  from  18  to  24. 

Case  CCL. — Male,  aged  forty  years,  fell  six  feet  into 
an  area  way;  consciousness  lost,  and  not  restored  at  time 
of  admission  to  hospital,  but  sensitiveness  to  external  im- 
pressions retained ;  profuse  hemorrhage  from  right  ear;  left 


552  IN'JURIES    OF    THE    BRAIN    AND    MEMBRANES. 

radial  pulse  fuller  and  stronger  than  the  right;  pupils 
contracted,  but  responsive  to  light;  right  corneal  reflex 
diminished ;  right  side  and  right  face  paretic,  and  urine 
retained.  The  pupils  became  normal  on  the  second  day, 
and  the  radial  pulses  symmetrical  on  the  third,  with  some 
signs  of  returning  consciousness.  Convulsive  movements 
of  the  extremities  occurred  on  the  fourth  day,  and  there 
was  some  dysphagia.  The  patient  gave  little  evidence  of 
intelligence  till  the  end  of  the  fourth  week ;  he  had  no 
power  of  speech  beyond  the  utterance  of  an  occasional 
single  word,  and  when  his  attention  could  be  attracted, 
which  was  not  often,  replied  only  in  inarticulate  sounds; 
he  rarely  recognized  his  immediate  family,  and  had  no 
apparent  comprehension  of  what  was  said  to  him.  The 
right  facial  paralysis  continued,  with  added  ptosis  of  the 
left  eye,  and  both  pupils  became  dilated.  His  mind  then 
became  clearer,  but  intelligence  was  very  limited ;  he  ar- 
ticulated several  words  with  moderate  distinctness,  and  a 
little  later  used  several  short  phrases  with  propriety ;  a  little 
later  still  his  attention  could  be  momentarily  fixed  to  com- 
prehend, and  answer  monosyllabically,  a  simple  question. 
An  ophthalmic  examination  made  by  Dr.  Callan  disclosed 
no  retinal  changes.  At  the  end  of  the  sixth  week  he  began 
to  notice  what  went  on  about  him,  recognized  his  mother, 
and  developed  destructive  tendencies.  Early  in  the 
seventh  week  he  first  gave  attention  to  the  natural  offices 
of  the  body,  and  his  increasing  range  of  words  accen- 
tuated his  aphasia.  After  the  second  month  there  was 
only  a  trace  of  facial  paralysis,  and  no  other  paretic  condi- 
tion. He  could  dress  himself,  and  went  about  the  ward; 
he  could- remember,  and  could  write  his  name  and  address 
correctly,  and  seemed  readily  to  understand  such  questions 
as  were  asked  him,  but  replied  in  an  endless  tirade  which 
was  incoherent  and  largely  made  np  of  inarticulate  sounds 
interspersed  with  recognizable  words,  and  apparently  as 
devoid  of  meaning  to  himself  as  to  the  listener.  He  was 
unable  to  write  from  dictation  more  than  a  few  words  be- 


CASES    UNVERIFIED    BY    NECROPSY.  553 

fore  the  written  characters  became  incomprehensible,  and 
he  repeated  words.  He  had  no  knowledge  of  his  occupa- 
tion, manner  of  injury,  or  local  surroundings.  He  was 
discharged  at  the  end  of  the  third  month,  and  had  then 
upon  cursory  examination  no  symptoms  of  mental  disorder 
remaining,  except  some  hesitancy  in  collating  words,  and 
in  long  sentences  a  little  confusion  in  expression.  If  an 
attempt  was  made,  however,  to  engage  him  in  a  sustained 
conversation,  his  thoughts  became  more  and  more  en- 
tangled; he  talked  rapidly  and  excitedly,  and  his  words 
were  inextricably  jumbled  together.  On  examination, 
four  months  later,  his  mental  condition  was  that  of 
dementia. 

The  temperature  on  admission  was  98.4°,  and  reached 
its  maximum,  102.6°,  on  the  second  and  third  days.  It 
then  gradually  but  irregularly  declined.  It  was  occasion- 
ally normal  after  the  first  week,  but  ordinarily  99°+  or 
100°,  quite  up  to  the  time  of  the  patient's  discharge  from 
the  hospital.  The  right  axillary  temperature  was  the 
higher  twenty-two  times,  and  the  left  twelve  times,  and 
the  two  were  uniform  once,  in  thirty-five  observations 
made  during  the  first  .nine  weeks.  The  left  was  afterward 
usually  two-tenths  to  four-tenths  of  a  degree  the  higher. 
The  pulse  did  not  exceed  90  after  the  fourth  day,  and  the 
respiration  was  at  no  time  more  than  22. 

Case  CCLI. — Male,  aged  forty  years,  fell  ten  feet  to  a 
ship's  deck;  consciousness  lost  for  twenty  minutes  and 
both  pupils  dilated.  On  admission  to  hospital,  hemor- 
rhage from  the  right  ear  and  nostril,  right  pupil  dilated, 
stupor,  and  temperature  of  97.6°.  The  right  radial  pulse 
at  this  time  was  92,  and  the  left  100,  in  the  minute.  The 
temperature  and  pulse  became  normal  in  three  hours ;  no 
further  symptoms  except  frontal  headache ;  no  memory  at 
any  time  of  having  been  injured. 

Case  CCLII. — Female,  aged  thirty-two  years,  fell 
down  a  companionway  on  board  ship,  was  found  uncon- 
scious, and  on  admission  to  hospital  thirty  minutes  later 


554  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

was  in  stupor,  with  profuse  hemorrhage  from  left  ear  and 
moderate  hemorrhage  from  both  nostrils;  pupils  normal, 
radial  pulsations  symmetrical,  and  no  muscular  disorders; 
temperature,  98.4°;  pulse,  60;  and  respiration,  20;  the 
right  axillary  temperature  was  96°,  and  the  left  gy.^". 
Later  symptoms  were  somnolence,  recurrence  of  hemor- 
rhage from  the  ear,  frontal  headache,  left  facial  paralysis, 
and  intermittent  active  delirium,  which  became  constant. 
The  temperature  gradually  increased  to  101  °-|-,  the  pulse 
was  58-82,  and  the  respiration  20,  18,  26.  On  the  fifth 
day,  delirium  increased  with  continued  pain  in  the  head, 
and  the  temperature  rose  from  101.6°  to  105.2°;  on  the 
seventh  day  the  left  pupil  was  contracted,  and  a  few  hours 
later  active  delirium  was  succeeded  by  stupor,  wide  dilata- 
tion of  right  pupil  and  slight  dilatation  of  the  left;  the 
temperature,  which  had  receded  to  103.4^-103°,  rose  to 
106°,  and  the  pulse,  which  had  ranged  from  59  to  68,  was 
accelerated  to  160,  and  the  respiration  to  60.  Death  oc- 
curred at  the  end  of  the  eighth  day;  temperature,  107.8°, 
with  immediate  post-mortem  recession. 

Case  CCLIII. — Male,  aged  fourteen  years,  fell  twelve 
feet,  striking  upon  his  head ;  primary  loss  of  conscious- 
ness ;  no  other  general  symptoms.  On  admission  to  hos- 
pital, sensitive  to  pain,  with  protrusion  of  both  eyes, 
rigidity  of  left  upper  extremity,  and  paralysis  of  the  right, 
and  compound  fracture  of  left  parietal  bone,  depressed 
and  extending  into  occipital  inferior  fossa;  osseous  frag- 
ments elevated.  Temperature  on  admission,  97.6°,  rose 
in  two  hours  to  101°;  pulse  76-80;  respiration,  22. 
Later,  rigidity  of  left  arm  disappeared,  paralysis  of  left 
continued;  eyes  turned  to  left;  loss  of  urinary  control; 
restlessness  and  unconsciousness;  temperature  rose  pro- 
gressively to  108°  at  the  time  of  death  in  fifty  hours,  with 
immediate  post-mortem  recession ;  the  pulse  and  respira- 
tion were  also  progressively  accelerated. 

Case  CCLIV. — Male,  aged  thirty-five  years,  found  un- 
conscious at  the  foot  of  a  flight  of  stairs.     On  admission 


CASES    UNVERIFIED    BY   NECROPSY.  555 

to  hospital,  complete  loss  of  consciousness,  hsematoma 
above  and  behind  right  ear,  free  hemorrhage  from  right 
ear  which  continued  five  hours,  left  pupil  dilated  and  im- 
movable, right  pupil  contracted  but  responsive  to  light, 
respiration  very  irregular,  right  radial  pulsations  fuller 
and  stronger  than  the  left,  retention  of  urine,  breath  alco- 
holic ;  and  a  little  later,  hemorrhage  from  the  right 
nostril.  Temperature,  96,4°;  pulse,  66.  On  the  second 
day,  sanguinolent  discharge  followed  by  brain  matter, 
which  continued  through  the  day  and  was  seen  to  ooze 
through  a  perforation  in  the  tympanum;  radial  pulsations 
symmetrical  in  the  evening.  On  the  third  day,  discharge 
from  the  ear  was  serous,  left  pupil  was  contracted,  and 
restlessness  continued.  During  the  week  following,  the 
right  and  left  radial  pulsations  were  alternately  the  fuller 
and  stronger,  except  as  at  times  they  were  symmetrical; 
there  was  slight  left  internal  strabismus,  the  mental  con- 
dition was  normal  except  for  occasional  delusions,  and  the 
left  pupil  was  appreciably  dilated.  There  were  no  later 
symptoms  save  occasional  diplopia,  and  a  persistent  delu- 
sion that  he  was  a  workingman  and  anxious  to  return  to 
his  work.  The  man  was  evidently  sincere,  but  a  typical 
tramp,  who  never  worked,  and  in  his  right  mind  entirely 
incapable  of  associating  such  an  idea  with  himself.  The 
temperature  became  normal  three  hours  after  admission, 
and  rose  to  102°  on  the  second  day;  it  varied  from  99°+  to 
I03°-|-  on  the  third  and  fourth  days,  from  102.8°  to  100.8° 
on  the  fifth,  sixth,  and  seventh  days,  from  101.6°  to  99.6° 
till  the  twelfth  day,  from  100.2°  to  99.8°  till  the  eighteenth 
day,  and  afterward  from  99.8°  to  99.6°;  pulse,  112  to 
normal;  respiration,   12  to  40 — ordinarily,  20-24. 

Case  CCLV.— Male,  fell  one  flight  of  stairs  while  in- 
toxicated. On  admission  to  hospital  next  day,  no  external 
injuries,  hemorrhage  from  right  ear,  somnolence,  pupils 
normal;  temperature,  100.4°;  pulse,  100;  respiration,  22. 
On  the  second  day,  vomiting,  restlessness,  and  severe 
headache ;  on  the  fourth  day,  watery  discharge  from  the 


556  INJURIES    OF    THE    BRAIN    AND    MEMBRANES. 

right  ear;  on  the  fifth  and  sixth  days,  delirium  following 
restlessness  and  headache  and  becoming  violent;  pulse 
and  temperature  not  increased  ;  from  seventh  to  tenth  days, 
restlessness,  delirium  at  times,  and  somnolence ;  from 
eleventh  to  sixteenth  days  occasional  delusions,  and  daily 
periods  of  restlessness  and  active  delirium ;  on  seventeenth 
and  eighteenth  days,  headache  unusually  severe  ;  nineteenth 
day,  temperature  became  and  continued  normal,  and  the 
memory  of  circumstances  attending  the  injury  was  restored, 
but  not  that  of  subsequent  events.  Afterward  there  were 
some  deafness  and  indistinctness  of  vision,  and  a  slightly 
staggering  gait  with  an  inclination  toward  the  left.  The 
temperature  rose  on  the  second  day  to  104.2°,  on  the  third 
and  fourth  days  to  103°-!-,  and  on  the  fifth,  sixth,  and 
seventh  days  to  102°,  with  moderate  recessions;  it  after- 
ward gradually  declined.  The  highest  pulse  was  112,  on 
the  fifth  day,  and  did  not  exceed  70  after  the  ninth  day. 
The  respiration  was  only  slightly  accelerated. 

Case  CCLVI. — Male,  aged  forty  years,  found  uncon- 
scious at  the  foot  of  a  flight  of  stairs,  with  hemorrhage 
from  mouth  and  nose.  On  admission  to  hospital,  loss 
of  consciousness  not  complete;  stertor;  temperature, 
97.4°;  pulse,  64;  respiration,  24;  condition  probably  alco- 
holic; pupils  sluggish  and  somewhat  contracted;  contu- 
sions of  face  and  head,  ecchymosis  of  both  eyes  and 
hemorrhage  from  mouth  and  nose ;  mental  condition 
normal  in  twelve  hours.  Through  the  first  week  noc- 
turnal delirium,  mental  confusion  by  day,  limited  frontal 
pain  with  some  frontal  oedema,  which  was  evident  on  the 
first  day;  and  at  the  end  of  the  week  exophthalmos  of 
the  left  eye  and  contraction  of  the  left  pupil;  temperature, 
99°-ioo°;  pulse,  60-52;  respiration,  16-14.  During  the 
second  week  inequality  of  pupils  persisted ;  an  examination 
of  the  eyes  by  Dr.  John  E.  Weeks  showed  that  the  ocular 
movements  were  limited  except  in  a  downward  direction, 
that  the  pupils  reacted  to  light,  that  the  retinal  arteries 
were  apparently  reduced  in  size,  that  the  temporal  half  of 


CASES    UNVERIFIED    BY   NECROPSY.  557 

the  retina  was  pale,  and  that  vision  was  good ;  temporary 
disturbance  of  vision  and  exophthahnos  were  probably  due 
to  effusion  into  orbital  tissue.  An  examination  by  Dr. 
Callan  two  weeks  later  showed  pronounced  pallor  of  the 
left  optic  nerve  most  marked  on  the  outer  side,  retinal 
arteries  decidedly  reduced  in  size,  nasal  field  restricted, 
and  vision  much  diminished. 

The  temperature  from  the  twelfth  to  the  twenty-third 
day  declined  each  day  to  97°—  or  97°+,  usually  from 
seven  to  nine  o'clock  in  the  morning,  but  occasionally  in 
the  evening.  On  the  thirty-fourth  day  it  fell  to  96.6°;  it 
exceeded  98.5°  on  but  two  or  three  occasions.  The  pulse 
was  from  54  to  60,  and  the  respiration  12-14. 

The  patient  left  the  hospital  with  no  symptoms  but 
those  of  failing  sight. 

Case  CCLVII. — Male,  adult,  fell  backward,  striking 
upon  the  back  of  his  head;  walked  to  two  other  hospitals 
and  afterward  to  Bellevue;  when  asked  his  name,  he  con- 
stantly reiterated,  "four  times;"  he  soon  became  inco- 
herent, very  restless,  and  required  mechanical  restraint; 
hemorrhage  from  left  ear,  and  for  a  short  time  contraction 
of  left  pupil.  Temperature,  102.4°,  104.8°,  103.6°;  pulse, 
68-120;  respiration,  20-24.  On  the  second  day,  coma, 
loss  of  urinary  control,  and  death.  Temperature,  104.4", 
108.2°,  with  immediate  post-mortem  recession;  pulse  and 
respiration  frequent. 

Case  CCLVIII. —  Male,  aged  thirty-one  years,  fell 
twenty  feet  into  ship's  hold;  primary  unconsciousness. 
On  admission  to  hospital,  somnolence,  vomiting,  and 
hemorrhage  from  the  left  ear,  which  continued  twenty-four 
hours;  pupils  slightly  dilated.  Temperature,  100.2°; 
pulse,  120;  respiration,  25.  The  patient  would  begin  to 
answer  a  question  and  suddenly  stop  short,  and  could  give 
only  the  first  part  of  his  name,  though  he  recognized  the 
rest  of  it  when  it  was  told  him.  On  the  second  day,  vom- 
iting, frontal  pain,  twitching  of  the  fingers  of  the  right 
hand  when  asleep,    somnolence,  and  apathy.      Tempera- 


558  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

ture,  ioi°-99°;  pulse,  1 15-80;  respiration,  28-22.  Head- 
ache and  delirium  whicli  were  not  constant  continued  till 
the  eighth  day,  and  occasional  attacks  of  headache  till  the 
end  of  the  third  week,  when  he  left  the  hospital. 

Case  CCLIX. — Male,  aged  twenty-six  years,  injured 
by  having  his  head  caught  in  its  occipito-mental  diameter 
between  a  descending  elevator  and  an  iron  bar.  On  ad- 
mission to  hospital,  hemorrhage  from  left  ear,  mouth, 
and  both  nostrils,  consciousness  unimpaired,  and  pain  in 
the  head,  most  severe  in  the  region  of  the  left  ear.  There 
were  no  external  injuries,  though  the  eyes  were  greatly 
swollen  and  closed  as  a  result  of  intracranial  lesion. 
Temperature,  98° ;  pulse,  66;  respiration,  18.  No  other 
symptom,  except  a  little  later  haematemesis. 

The  swelling  in  the  palpebral  regions  and  the  hemor- 
rhage from  the  ear  gradually  disappeared  during  the 
week;  the  temperature  rose  to  101.4°  on  the  second  day 
and  then  declined  to  normal,  without  further  disturbances. 

Case  CCLX. — Male,  aged  forty-five  years,  fell  eigh- 
teen feet,  striking  upon  his  head;  primary  unconscious- 
ness. On  admission  to  hospital,  semi-consciousness,  hem- 
orrhage from  right  ear,  mouth,  and  both  nostrils  with 
haematemesis  and  no  other  symptoms.  Temperature, 
97.4°;  pulse,  100 ;  respiration,  60.  Consciousness  was  fully 
restored  in  ten  hours;  severe  frontal  pain  persisted 
till  the  sixth  day,  when  it  became  occipital ;  no  later 
symptoms,  and  no  headache  when  discharged  from  the 
hospital  on  the  eleventh  day;  highest  temperature,  100.4°; 
pulse,  120-90. 

Case  CCLXI. — Male,  aged  forty-five  years,  fell  twelve 
feet;  transient  primary  unconsciousness.  On  admission 
to  hospital,  hemorrhage  from  right  ear,  slight  dilatation 
of  right  pupil,  pain  in  the  right  ear,  nausea,  and  no 
other  symptoms.  Temperature,  97.8°;  pulse,  100;  respi- 
ration, 24.  One  hour  later,  right  radial  pulse  fuller  and 
stronger  than  the  left.  On  the  second  day,  frequent 
vomiting,    delirium;    temperature,    ioo.4°-ioi.2° ;    pulse, 


CASES    UNVERIFIED    BY    NECROPSY.   •  559 

96-100 ;  respiration,  20-24.  ^^  the  third  day,  mind 
clear,  both  pupils  moderately  dilated,  the  right  more  than 
the  left,  severe  pain  in  the  frontal  region  and  right  ear,  and 
ecchymosis  apparent  in  right  mastoid  region.  No  further 
general  symptoms  during  the  week.  The  patient  when 
discharged  in  the  second  week  had  deafness  in  the  right 
ear,  impaired  memory,  and  some  mental  aberration. 

Case  CCLXII. — Male,  aged  thirty  years,  fell  five 
stories,  striking  upon  his  head  and  shoulder;  found  un- 
conscious; small  haematoma  in  left  frontal  region,  hemor- 
rhage from  both  ears,  nose,  and  mouth  ;  right  pupil  dilated, 
muscular  twitching  in  right  arm,  and  fracture  of  right 
radius  and  ulna.  On  admission  to  hospital,  patient 
restless  and  slightly  delirious ;  fracture  not  disclosed  by 
incision.  On  the  second  and  third  days,  frontal  pain,  de- 
lirium, and  lack  of  urinary  control.  On  the  fourth  day 
there  were  noted  an  indistinctness  of  articulation,  and  a 
profuse  perspiration,  which  continued  at  intervals  while 
the  patient  remained  in  the  hospital.  The  perspiration 
usually  began  about  seven  o'clock  each  evening  and  lasted 
two  hours,  but  the  time  was  not  invariable.  For  several 
days  the  mental  condition  and  urinary  control  were 
normal  by  day,  with  delirium  and  loss  of  urinary  control 
each  night.  On  the  sixth  day  there  were  diplopia  and 
internal  strabismus,  and  on  the  seventh,  the  appearance 
of  left  subconjunctival  hemorrhage.  On  the  eighth  day 
delirium  ceased,  and  urinary  control  Avas  permanently 
restored.  On  the  tenth  day  examination  of  the  eyes  by 
Dr.  Callan  disclosed  hyperaemia  and  blurring  of  both 
optic  discs.  The  patient  was  removed  from  the  hospital 
on  the  fifteenth  day;  at  that  time  articulation  was  more 
distinct,  but  the  perspirations  were  not  diminished.  The 
temperature  was  normal  on  admission  and  was  afterward 
usually  99°H — 100°+'  occasionally  rising  to  101^-102°;  the 
pulse  declined  from  112  to  88;  respiration,  22-26. 

Case  CCLXIII. — Male,  aged  fifty-five  3-ears,  struck  on 
the  head  by  a  descending  elevator;  dazed.     On  arrival  of 


560  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

ambulance,  the  patient  was  unable  to  speak,  but  had  per- 
fect comprehension  of  what  was  said  and  of  all  that  went 
on  about  him ;  compound  linear  fracture  of  left  parietal 
bone  posteriorly  and  extending  through  mastoid  process 
into  posterior  fossa;  hemorrhage  from  left  ear,  mouth, 
and  left  nostril;  left  pupil  contracted;  same  conditions  on 
admission  to  hospital.  On  the  second  day  incomplete 
paralysis  of  the  muscles  of  the  lower  face  and  tongue,  and 
later  dysphagia,  with  pain  in  the  head  and  restlessness. 
The  paralysis  continued,  with  improvement  in  the  general 
condition  when  discharged  on  the  thirteenth  day.  Tem- 
perature, 98°,  ioo°-|-,  98°  —  ;  pulse,  78,  92,  76;  respiration, 
12,  26,  22. 

Case  CCLXIV. — Male,  aged  eight  years,  knocked 
down  by  a  bicycle ;  transient  loss  of  consciousness,  profuse 
hemorrhage  from  right  ear,  vomiting;  temperature,  98°; 
pulse,  98;  respiration,  26.  Hemorrhage  ceased  on  the 
seventh  day;  a  later  serous  discharge  continued  when  the 
patient  left  the  hospital  on  the  twenty-sixth  day ;  no  other 
symptom  except  pain  in  the  right  side  of  the  face  and 
ear;  temperature  once  reached  103.4°,  apparently  from 
pain  and  a  disturbance  of  digestion  with  constipation. 

Case  CCLXV. — Male,  aged  twenty-four  years,  fell 
twenty  feet,  striking  upon  his  head ;  no  loss  of  conscious- 
ness and  mental  condition  normal :  compound  linear  frac- 
ture in  left  occipital  bone ;  moderate  hemorrhage  from 
the  left  ear;  no  other  symptoms.  Patient  walked  to  the 
ward  and  was  immediately  seized  with  a  severe  general 
convulsion,  followed  by  severe  pain  in  the  head  which 
continued  for  one  week.  Temperature  on  admission, 
100°,  and  did  not  afterward  exceed  that  degree;  pulse, 
88-64;  respiration,  20,  24,  16. 

Case  CCLXVI. — Male,  aged  thirty-one  years,  was 
struck  by  a  brick  which  had  fallen  five  stories;  no  other 
immediate  general  symptom  but  unconsciousness.  A  com- 
pound depressed  fracture  crossed  the  median  line  at  the 
vertex.      Second    day,  there    was    accurate    memory   of 


CASES    UNVERIFIED    BY   NECROPSY.  561 

events  up  to  the  time  of  injury,  no  recollection  of  any- 
thing that  occurred  afterward.  Third  day,  fragments  of 
depressed  bone  were  removed,  leaving  an  opening  in  the 
skull  two  by  one  and  a  half  inches  in  its  diameters ;  no 
lesion  of  dura  mater  or  of  the  sinus.  Temperature  on 
admission,  104.4°;  at  time  of  operation,  100°;  subsequently 
99°+.     Pulse  and  respiration  at  all  times  normal. 

Case  CCLXVII.  —  Male,  aged  thirty-three  years, 
struck  on  the  head  with  a  hammer  and  momentarily  un- 
conscious, after  which  he  walked  to  the  hospital.  Com- 
pound depressed  fracture  of  the  mid-vertex;  both  pupils 
dilated ;  left  radial  pulse  markedly  fuller  and  stronger 
than  the  right  till  after  operation,  five  days  later;  no 
other  general  symptoms.  Depressed  fragments  of  bone 
were  removed,  leaving  an  opening  in  the  skull  one  and  a 
half  inches  by  one  inch  in  its  diameters ;  hemorrhage  from 
a  large  wound  of  the  longitudinal  sinus  controlled  by 
gauze  packing.  Pulse  and  respiration  became  normal  on 
the  following  day,  and  radial  pulsations  symmetrical  on 
the  third  day.  Elevation  of  temperature  was  maintained 
by  a  slough  and  inflammatory  conditions  produced  by  an 
accidental  burn.  Temperature  on  admission  was  99.2°, 
rose  in  a  few  hours  to  101.4°,  a^^d  after  the  operation  to 
i02°-f-;  pulse  and  respiration,  normal  at  first,  were  subse- 
quently only  moderately  accelerated. 

Case  CCLXVIII. — Male,  aged  eight  years,  kicked  in 
the  forehead  by  a  horse :  compound  depressed  fracture  of 
right  frontal  bone,  just  above  frontal  sinus,  and  near 
median  line;  no  loss  of  consciousness;  depressed  bone 
elevated  and  spicula  removed,  leaving  an  opening  three- 
fourths  of  an  inch  in  diameter;  dura  mater  uninjured. 
Temperature  normal  to  99°+  till  the  fifth  day,  when  it 
rose  to  103°,  and  on  the  sixth  to  104°;  on  the  seventh  day 
it  declined  to  102.8°,  and  on  the  ensuing  four  days  was 
101°;  it  was  then  99°+  for  ten  days  longer.  On  the 
fifteenth  day  there  was  a  free  discharge  of  serous  fluid, 
and  the  patient,  who  for  twenty-four  hours  had  been  som- 
36 


562  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

nolent,  immediately  aroused.  On  the  twentieth  day  one 
or  two  drachms  of  laudable  pus  w^elled  up  through  the 
wound,  and  a  probe  was  inserted  two  and  one-half  inches 
directly  backward  and  for  the  same  distance  along  the  ex- 
ternal surface  of  the  lobe.  On  the  following  day,  under 
ether  the  dural  opening  was  enlarged  and  from  two  to  three 
ounces  of  pus  were  evacuated.  The  cavity  was  irrigated 
with  sol.  hyd.  perchlor.,  1-10,000,  and  drained  by  a  tube. 
The  temperature  rose  on  the  next  day  from  99.5°  to 
ioo.6°-i02°,  and  on  the  third  day  declined  to  100°  and  on 
the  sixth  to  99°;  it  was  afterward  99"^+  to  98.5°.  No 
general  symptom  succeeded  the  operation  except  incom- 
plete left  lower  facial  paralysis;  no  mental  disorder  at  any 
time.  The  facial  paralysis  disappeared  on  the  tenth  day. 
A  fungus  cerebri  became  evident  on  the  seventh  day; 
the  wound  was  entirely  healed  forty-two  days  after  opera- 
tion. 

Case  CCLXIX. — Male,  aged  forty-four  years,  was 
admitted  to  the  alcoholic  ward  and  next  day  transferred  to 
the  surgical  service  of  the  hospital.  On  admission  he 
was  completely  unconscious,  with  rigidity  of  the  muscles 
of  left  upper  and  lower  extremities,  and  irregular  pupils. 
On  reception  into  a  surgical  ward  consciousness  had  been 
in  part  regained  and  rigidity  had  been  replaced  by  left 
hemiplegia  and  hemiansesthesia ;  there  were  abrasion  of  the 
nose,  contusion  of  the  left  eye,  arid  oedema  of  the  right 
occipito-parietal  region.  On  the  fifth  day  hemiplegia  had 
become  complete,  movements  from  the  bowels  were  con- 
scious but  involuntary,  and  speech  was  rambling;  the 
mental  condition  w^as  otherwise  normal,  and  the  patient's 
explanation  of  his  hurt,  that  he  fell  and  was  struck  by  a 
plank,  never  varied.  An  incision  was  made  over  the  right 
motor  area,  an  open  fissure  which  crossed  the  parietal 
bone  obliquely  and  extended  into  the  occipital  was  dis- 
closed, and  a  large  cranial  opening  made  by  the  trephine 
and  rongeur.  An  epidural  clot  extended  from  the  coronal 
suture    into    the   superior   occipital    fossa,   and    from    the 


CASES    UNVERIFIED    BY    NECROPSY.  563 

median  line  to  the  base;  it  \s'as  one  and  one-half  inches  in 
thickness  at  the  site  of  trephination,  and  measured  four 
and  one-half  fluid  ounces.  The  dura  mater  was  unin- 
jured. As  hemorrhage  \Yas  free  from  some  inaccessible 
point  beneath  the  bone,  posteriorly,  the  large  cavity  was 
packed  with  gauze,  which  Y-as  removed  some  hours  later. 
In  tY'o  hours  after  operation  there  was  some  motility  of 
the  left  leg  and  in  tY^elve  hours  sensibility  of  the  left 
arm.  On  the  folloY^ing  day  temperature  Y-as  normal  and 
faecal  control  Y-as  regained.  On  the  second  day  the 
brain  had  regained  the  volume  lost  by  compression;  mind 
clear. 

Case  CCLXX. — Male,  aged  tY-enty-five  3'ears,  Y-as 
struck  with  an  iron  poker;  no  loss  of  consciousness;  com- 
pound linear  fracture  of  left  parietal  bone ;  paralysis  of 
right  forearm  and  sensation  of  numbness ;  no  pain  or  ele- 
vation of  temperature ;  trephination  and  removal  of  several 
small  depressed  fragments  of  inner  table  of  bone ;  no  ap- 
parent subdural  lesion.  Temperature  rose  to  ioi°+. 
Paralysis  had  diminished  at  time  of  patient's  removal  from 
hospital. 

Case  CCLXXI. — Male,  aged  fifty-five  years,  returned 
to  his  house  in  a  dazed  condition  and  unable  to  speak.  On 
admission  to  the  hospital  complete  motor  aphasia^  and 
tw^o  hours  later  incomplete  paralysis  of  right  upper  ex- 
tremity which  rapidly  increased.  Temperature,  100.2°; 
pulse,  104.  A  compound  fracture  of  the  left  parietal 
bone,  nearly  circular,  three-fourths  of  an  inch  in  diameter, 
Y'as  situated  just  above  the  fissure  of  Sylvius  and  just  be- 
hind the  fissure  of  Rolando.  Operation:  dural  wounds 
enlarged;  cerebral  laceration  discovered,  which  extended 
into  lateral  ventricle ;  clot  of  large  size  extruded;  wound 
lightly  tamponed  and  closed  in  part  of  its  extent.  The 
paralysis  immediately  diminished,  but  anaesthesia  and 
aphasia  were  not  improved  till  the  third  week.  A  small 
fungus  cerebri  appeared  on  the  fourth  day,  over  which  on 
the  tenth  day  the  scalp  Y^as  sutured;  there  was  then  right 


564  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

facial  paralysis,  and  the  mental  condition  was  dull.  From 
the  third  week  the  fungus  gradually  disappeared  under 
firm  pressure,  brachial  motion  and  sensation  v/ere  grad- 
ually restored,  and  aphasia  slowly  diminished.  The  tem- 
perature but  twice  reached  101°;  the  pulse  was  usually 
80;  and  the  respiration,  20-16.  At  the  end  of  two  months 
the  only  remaining  symptom  was  a  slight  difficulty  in 
speaking  w^hen  under  excitement. 

Case  CCLXXII.— Male,  aged  thirty-eight  years,  fell 
from  a  second-story  window ;  delirious  and  but  semi-con- 
scious upon  immediate  admission  to  the  hospital,  and  in 
same  condition  when  transferred  from  alcoholic  ward  to  a 
surgical  service  next  day.  Compound  depressed  fracture 
of  left  temporal  bone  extending  into  superior  occipital 
fossa;  unsymmetrical  dilatation  of  the  pupils;  pulse  full 
and  slow;  breathing  stertorous;  no  control  of  urine  and 
faeces.  The  bone  was  elevated,  and  an  epidural  clot 
which  extended  only  toward  the  base  was  removed  as  far 
as  practicable;  no  discoverable  dural  or  subdural  lesion. 
Third  day,  left  radial  pulse  fuller  and  stronger  than  the 
right;  partial  left  lower  facial  paralysis  and  dysphagia; 
fourth  day,  violent  delirium;  fifth  day,  dysphagia  and 
cessation  of  bilateral  variation  in  radial  pulse;  delirium 
continued  with  a  short  interval,  in  w^hich  it  intermitted. 
The  symptoms  were  variable  until  the  end  of  the  fourth 
week ;  delirium  of  different  grades  at  different  times  al- 
ternated with  periods  of  quietude  and  rational  intelli- 
gence ;  various  delusions  were  more  or  less  persistent ; 
dysphagia,  lack  of  urinary  and  faecal  control,  and  facial 
paralysis  still  continued.  After  this  time  mental  improve- 
ment was  progressive,  and  in  the  seventh  week  the  mind 
was  clear.  At  the  end  of  eight  weeks  recovery  was  com- 
plete, and  twenty  pounds  lost  in  weight  had  been  re- 
gained. The  temperature  on  admission  was  97.6°,  on  the 
second  day  102°,  and  after  operation  104.4°;  it  declined  to 
normal  at  the  end  of  the  second  week  and  subsequently 
varied  from  normal  to  99°+-     The  pulse  and  respiration 


CASES    UNVERIFIED    BY    NECROPSY,  565 

were  never  frequent.  No  mental  impairment  existed 
when  patient  was  examined  fifteen  months  later. 

Case  CCLXXIII.— Male,  aged  thirty-five  years,  fell 
while  dancing  and  struck  the  back  of  his  head  on  the  ball- 
room floor;  no  loss  of  consciousness,  and  no  other  indica- 
tion of  injury  till  thirty  minutes  afterward,  when  the  right 
upper  eyelid  began  to  droop.  On  examination  five  hours 
later,  symptoms  were  confined  to  right  eye  and  appen- 
dages; complete  ptosis,  external  strabismus,  paresis  of  all 
the  ocular  muscles,  imperfect  accommodation,  and  diplo- 
pia; normal  pupil  and  retina.  At  the  end  of  eighteen 
months  there  was  still  some  weakness  of  the  ocular 
muscles,  but  no  ptosis.  The  right  pupil  was  permanently 
dilated. 

Case  CCLXXIV. — Male,  aged  twenty-eight  years, 
received  a  contusion  of  the  right  parietal  region,  and  on 
the  second  day  began  to  exhibit  symptoms  which  were 
observed  at  the  time  of  examination  ten  days  later:  wide 
dilatation  of  left  pupil;  incomplete  paralysis  of  all  the 
ocular  muscles  and  of  the  elevator  of  the  upper  lid  of  the 
left  eye ;  anaesthesia  of  the  left  conjunctiva  and  of  the 
mucous  membrane  of  the  left  nostril,  with  loss  of  smell  on 
that  side;  and  intense  and  constant  pain  in  all  the  parts 
included  in  the  distribution  of  the  fifth  cranial  nerve  on 
the  left  side.  No  paralysis  of  the  facial  muscles.  Some 
numbness  of  the  left  upper  extremity.  No  other  symp- 
toms. Ophthalmic  examination  by  Dr.  Callan  disclosed 
some  cloudiness  of  the  fundus  and  enlargement  of  its 
veins  in  both  eyes ;  accommodation  very  imperfect.  Two 
weeks  after  the  injury  the  hearing  in  the  left  ear  was  lost. 
The  patient  eventually  entirely  recovered. 

Case  CCLXXV. — Male,  aged  sixty-five  years,  fell 
thirty  feet;  consciousness  lost,  and  regained  twenty  hours 
after  admission  to  the  Presbyterian  Hospital;  left  hemi- 
plegia; temperature,  98°,  which  fell  in  four  hours  to  97°; 
pulse,  70  to  80 ;  normal  pupils ;  lacerated  wound  of  scalp. 
Transferred  to   Belleuve   Hospital   eighty-two  hours  after 


566  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

reception  of  the  injury.  There  were  then  delirium  with 
delusions;  restlessness;  no  recognition  of  changed  sur- 
roundings; normal  pupils  and  respiration;  no  paralysis; 
temperature,  100.5°;  pulse,  112.  For  ten  days  continued 
restlessness  and  at  times  delirium,  with  lack  of  urinary 
control;  temperature,  102.6°;  pulse  and  respiration  mod- 
erately accelerated.  After  that  time  mental  condition 
became  normal,  at  first  only  during  the  day,  and  all  symp- 
toms disappeared.  Seventeen  months  afterward  his  men- 
tal and  physical  condition  was  entirely  restored. 

Case  CCLXXVI. — Male,  aged  thirty-one  years,  fell 
two  stories  upon  an  iron  beam ;  unconscious  and  delirious 
on  immediate  admission.  Wound  above  the  left  eye  and 
contusion  of  the  left  shoulder;  loss  of  urinary  and  faecal 
control,  which  was  not  regained.  Subsequently  the 
patient  was  usually  delirious  at  night  and  stupid  during 
the  day,  and  without  other  general  symptoms;  he  was 
only  once  or  twice  able  to  make  coherent  reply  to  a  ques- 
tion asked.  He  died  in  profound  coma  at  the  end  of 
twelve  days.  Temperature  on  admission  was  99°,  rose 
gradually  to  105°  on  the  ninth  day,  and  was  104.8°  just 
before  death.  The  pulse  was  82  on  admission  and  the 
respiration  24,  and  both  afterward  varied  each  day  from 
moderate  to  extreme  frequency. 

Case  CCLXXVII.— Male,  aged  thirty-two  years,  fell 
from  his  truck  and  struck  the  back  of  his  head  upon  the 
pavement ;  partial  loss  of  consciousness  and  delirium,  which 
continued  for  three  days.  Fourth  day,  limited  power  of 
comprehension,  no  response  to  questions  asked,  attention 
fixed  only  with  difficulty,  occipital  headache  which  was 
not  increased  by  pressure  or  percussion,  and  somnolence. 
At  the  end  of  four  weeks  the  patient  sat  up,  but  walked 
with  difficulty  on  account  of  imperfect  muscular  co-ordina- 
tion in  both  legs ;  patellar  reflexes  normal ;  mind  clear  but 
slow  in  action,  which  he  himself  noted ;  vertigo,  which 
was  not  of  previous  occurrence ;  occipital  headache  re- 
lieved.    Dr.  P.  A.  Callan  discovered  upon   ocular  exam- 


CASES    UNVERIFIED    BY   NECROPSY.  567 

ination  a  neuritis,  more  advanced  upon  the  right  side  than 
upon  the  left,  and  a  paralysis  of  the  ocular  muscles. 
Temperature  on  admission  was  99°,  rose  to  100.4°  on  the 
same  day,  was  from  99°  to  101°  till  the  sixth  day,  98.5°  to 
99°+  till  the  twenty-first  day,  and  afterward  continuously 
normal.  The  pulse  was  normal.  The  respiration  was  12 
for  three  days,  16  to  18  for  six  days,  8  to  12  for  thirteen 
days,  and  afterward  16  to  20. 

Case  CCLXXVIII.  —  Male,  aged  thirty  years,  fell 
twenty-five  feet  from  a  ship's  deck  to  a  raft  alongside j  con- 
sciousness lost  for  a  few  moments  only;  haematoma  over 
the  right  posterior  parietal  region  ;  moderate  contraction  of 
the  left  pupil ;  right  radial  pulse  fuller  than  the  left ;  urine 
retained ;  complete  paralysis  of  the  left  lower  extremity ; 
nearly  complete  paralysis  of  the  left  arm ;  partial  paralysis 
of  the  right  upper  extremity ;  anaesthesia  of  the  right  side 
of  the  body  below  the  third  rib;  hyperassthesia  of  the  left 
lower  extremity;  great  pain  and  tenderness  in  cervico- 
dorsal  region,  and  evident  fracture  of  the  first  dorsal 
spine;  mental  condition  apparently  normal. 

During  the  first  week  vomiting  occurred  at  least  once 
in  each  twenty-four  hours,  and  pain  in  the  frontal  and  in, 
the  upper  dorsal  region  was  constant  and  severe.  The 
bilateral  variation  of  the  pulse  was  distinct  till  the  fifth 
day.  The  paresis,  hyperaesthesia,  and  anaesthesia,  and 
the  contraction  of  the  left  pupil  persisted  in  greater  or  less 
degree  for  several  months  and  a  paresis  of  the  left  lower 
extremity  and  the  anaesthetic  and  hyperaesthetic  condi- 
tions and  the  contracted  pupil  existed  at  the  time  of  final 
discharge  from  the  hospital. 

An  ophthalmic  examination  was  made  by  Dr.  Callan, 
and  repeated  at  a  later  period,  with  negative  result.  The 
eye  was  retracted  and  a  little  less  sensitive  than  the  other, 
.but  there  was  no  retinal  change,  and  no  loss  of  power  in 
the  ocular  muscles. 

There  was  no  mental  disturbance  till  the  occurrence 
of   nocturnal    delirium  and  restlessness  at  the  beginning 


568  INJURIES    OF   THE    BRAIN    AND    MEMBRANES. 

of  the  third  week.  A  few  days  later  the  nocturnal  de- 
lirium ceased,  but  the  restlessness  at  night  increased, 
and  delusions  of  a  painful  character  began  to  occur, 
which  occasioned  the  patient  much  distress.  The  first 
trouble  which  came  to  him  was  the  fancied  death  of 
his  wife,  and  when,  a  little  later,  he  became  convinced 
that  this  bereavement  Vv-as  imaginary,  he  was  equally  posi- 
tive that  another  delusion,  the  death  of  his  child,  was  real, 
and  this  new  conceit  possessed  his  mind  for  many  weeks. 
He  suffered  acute  mental  anguish  in  each  instance,  which 
could  have  been  scarce  exceeded  had  these  pure  fancies 
been  actual  facts.  The  facial  expression  grew  a  little 
stupid,  and  an  inclination  to  weep  was  manifested  on 
ordinary  occasions,  equally  when  the  amount  of  cutaneous 
hyperaesthesia  was  tested,  or  when  discourse  turned  upon 
his  family  afflictions,  but  speech  was  always  coherent.  At 
the  end  of  the  second  month  there  was  some  improvement; 
the  facial  expression  brightened,  delusions  were  less  con- 
stant and  of  a  more  trivial  character,  and  the  mental  con- 
dition was  less  uniformly  clouded.  In  the  third  month 
delusions  altogether  disappeared,  and  mental  processes, 
though  slow,  were  no  longer  distorted ;  he  was  enabled  for 
the  first  time  to  recall  the  manner  of  his  injury;  vertigo, 
which  had  been  an  early  symptom,  still  persisted. 

The  temperature  on  admission  was  98.4°,  rose  during 
the  day  to  101.8°,  and  on  the  fifth  day  reached  105°.  It 
was  habitually  high  till  late  in  the  second  month  at  some 
time  in  each  twenty-four  hours,  not  less  than  ioi°-|-  to 
102°-)-,  the  diurnal  variations  being  also  considerable. 
The  left  axillary  temperature  was  markedly  higher  than 
the  right,  usually  five-tenths  of  a  degree  or  even  more. 
The  pulse  was  ordinarily  from  80  to  90,  occasionally  60  to 
70,  and  rarely  exceeded  100.  The  respiration  during  the 
first  month  was  not  often  less  than  30  and  later  ranged 
from  28  to  24. 

The  patient  left  the  hospital  seven  months  after  ad- 
mission.    There  was  then  no  trace  remaining  of  the  cere- 


CASES    UNVERIFIED    BY   NECROPSY.  569 

bral  injury  beyond  a  little  heaviness  of  manner  and  a  little 
slowness  of  thought.  The  persistence  of  the  spinal 
lesions  was  indicated  by  a  stationary  paresis  of  the  left 
lower  extremity  and  by  a  continuance  of  the  disorders  of 
sensation  which  immediately  followed  the  traumatism. 
The  left  eye  was  still  retracted  and  insensitive,  and  its 
pupil  small. 

Case  CCLXXIX. — Male,  aged  nine  years,  fell  ten 
feet  from  a  dump  into  a  scow ;  consciousness  lost  for  fif- 
teen minutes;  no  external  injury;  temperature,  98.2°; 
pulse,  67;  respiration,  28.  Third  to  fifth  days,  right 
radial  pulse  fuller  and  stronger  than  the  left ;  somnolence 
till  seventh  day,  and  recurrence  on  the  tenth  and  eleventh 
days  with  a  condition  of  mental  indifference ;  occipital 
pain  continued  at  intervals  during  ten  days.  The  tem- 
perature five  hours  after  admission  was  100.2°,  in  twelve 
hours  was  101°,  and  did  not  exceed  that  degree;  it  was 
qq""-!-  to  100°-]-  for  fourteen  days,  with  an  occasional  de- 
cline to  normal  for  a  single  observation  or  for  a  few  hours. 
The  axillary  temperatures  were  observed  four  times  daily, 
and  the  left  was  habitually  six-tenths  of  a  degree  or  more 
higher  than  the  right,  and  sometimes  the  difference  was 
as  great  as  a  degree  and  eight-tenths ;  they  were  occasion- 
ally symmetrical,  but  in  sixty-eight  observations  the  right 
was  never  the  higher.  The  pulse  was  usually  52  to  84, 
and  more  frequently  approximated  the  lower  figure.  The 
respiration  was  from  18  to  28. 

Case  CCLXXX. — Male,  aged  forty-two  years,  fell  in 
the  street,  striking  the  back  of  his  head;  consciousness 
lost,  but  regained  on  the  way  to  the  hospital ;  mental  con- 
dition stupid,  but  rational,  becoming  normal  in  a  few 
hours;  slight  general  headache;  later,  frontal  pain,  fol- 
lowed same  day  by  a  single  general  convulsion  of  five 
minutes'  duration;  head  and  eyes  turned  to  the  right;  left 
side  and  extremities  actively  convulsed ;  right  arm  and  leg 
motionless.  On  the  third  day  there  was  transient, pos- 
terior cervical  rigidity,  and  on  the  third  and  fourth   days 


5/0  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

the  left  radial  pulse  was  fuller  and  stronger  than  the  right. 
During  the  first  ten  days  the  patient's  condition  was 
marked  by  stupor,  occasional  somnolence,  slowness  or  re- 
fusal to  answer  when  questioned,  nocturnal  delirium 
becoming  continuous,  frontal  pains,  and  contracted  pupils. 
In  the  week  following  there  were  delusions,  lack  of  fsecal 
and  urinary  control,  increased  somnolence  and  stupor, 
some  muttering  delirium,  and  pains  in  the  back  of  the 
head  and  left  extremities,  suceeded  by  left  paresis.  After 
this  time  the  patient  occasionally  indicated  more  intelli- 
gence when  roused  from  his  habitual  stupor,  and  once 
conversed  intelligently  with  his  wife.  The  pupils  re- 
mained contracted  and  insensitive  to  light,  the  urine  and 
faeces  uncontrolled,  the  limbs  drawn  upward,  and  any  dis- 
turbance of  the  left  side  of  the  body  was  resented.  On 
the  twenty-fifth,  the  last  day  of  life,  articulation  in- 
distinct, deglutition  difficult,  and  death  preceded  by  rest- 
lessness and  some  brightening  of  the  mental  condition. 
The  temperature  on  admission  was  98°,  rose  to  103.2°  on 
the  third  day,  and  was  subsequently  99°  to  ioo°-l-  till  the 
last  day,  when  it  was  107.2°.  The  pulse  on  admission  was 
80,  on  the  fifth  day  42  to  58,  and  at  other  times  68  to  100. 
The  respiration  varied  from  18  to  24.  A  few  hours  before 
death  both  pulse  and  respiration  became  frequent. 

Case  CCLXXXI. — Male,  aged  twenty  {cafe  au  lait)\ 
of  feeble  intelligence.  Was  admitted  to  Bellevue  after 
one  day  at  the  Harlem  Hospital.  He  had  been  struck  by 
a  bootblack  or  b}'-  a  railroad  bridge,  as  it  occurred  to  his 
mind  at  different  times.  He  had  a  trivial  scalp  wound  in 
the  left  parietal  region  near  the  median  line  and  a  large 
hsematoma  extending  from  that  point  outward  and  back- 
ward. He  had  no  general  symptoms  except  paraplegia 
with  flaccid  muscles.  There  had  been  no  paralvsis  pre- 
vious to  injury,  and  there  was  no  evidence  of  specific 
disease.  The  case  was  regarded  as  one  of  pial  hemor- 
rhage involving  both  motor  areas,  and  iodide  of  potas- 
sium was  administered ;  recovery  was  rapid. 


CASES    UNVERIFIED    BY   NECROPSY.  57 1 

Case  CCLXXXII.  —  Male,  aged  twenty-one  years, 
found  unconscious  in  the  street;  regained  consciousness 
after  some  hours.  He  was  then  unable  to  give  his  sur- 
name, or  to  speak  beyond  reiterating  his  Christian  name. 
On  admission  to  the  hospital,  restlessness,  general  muscu- 
lar rigidity,  hyperaesthesia,  dilatation  of  both  pupils  which 
responded  slowly  and  only  to  strong  light,  and  a  small 
wound  in  the  right  temporal  region ;  no  fracture  disclosed 
by  incision.  The  muscular  rigidity  diminished  and  on 
the  third  day  there  was  evident  a  slight  left  facial  paraly- 
sis. The  subsequent  symptoms  were  essentially  mental. 
The  patient  at  the  end  of  the  first  week  was  actively 
delirious,  and  in  the  second  week  was  the  subject  of 
various  delusions,  and  his  speech  though  coherent  was  volu- 
ble and  his  words  were  foolish.  In  the  third  and  fourth 
weeks  his  demeanor  was  more  natural  and  his  mind 
clearer  but  weak;  he  remembered  some  of  the  circum- 
stances which  preceded  his  injury,  but  nothing  which 
occurred  from  that  time.  He  was  unable  to  write  figures 
correctly,  writing  186  for  180  or  490005  for  495,  and  he 
insisted  that  he  was  born  in  1891,  the  ensuing  year.  The 
temperature  never  exceeded  101°,  nor  after  the  first  five 
days  99°+;  the  pulse  was  58  to  88. 

The  patient  revisited  the  hospital  two  months  after  his 
discharge,  and  was  then  noisy  and  excitable. 

Case  CCLXXXHI. — Male,  aged  forty-seven  years, 
was  knocked  down,  the  back  of  his  head  striking  heavily 
upon  the  pavement.  On  admission  to  the  hospital,  loss 
of  consciousness,  stertor,  and  slight  contusions  of  the  face; 
pupils  normal  and  pulse  72  ;  subsequent  delirium  subsid- 
ing into  stupor,  inability  of  articulation,  dysphagia,  and 
left  facial  paralysis ;  and  later  gradual  improvement  until 
the  end  of  the  third  week,  when  there  were  for  a  few  days 
some  irritability  and  mild  delirium.  From  that  time  until 
he  left  the  hospital  late  in  the  second  month  the  patient 
had  no  memory  of  events  immediately  preceding  his  in- 
jury or  of  later  occurrence,  and  no  recognition  of  his  sur- 


5/2  IN'JURIES    OF   THE    BRAIN   AND    MEMBRANES. 

roundings.  He  usually  thought  that  he  was  in  a  manu- 
factory and  that  the  medical  men  were  foremen,  or,  it 
might  be,  lawyers.  His  memory  of  distant  events  was 
confused,  his  laugh  was  rather  vacant,  and  there  was  some 
loss  of  muscular  power  on  the  right  side.  The  temper- 
ature on  admission  was  ioo°-(-,  and  later  varied  from  that 
degree  to  99°. 

Case  CCLXXXIV.  —  Male,  aged  twenty-one,  was 
found  unconscious  in  the  street  and  was  supposed  to  have 
been  assaulted.  On  admission  to  the  hospital,  conscious- 
ness regained,  expression  of  the  face  vacant,  slight  wound 
above  the  left  superciliary  ridge ;  subsequent  symptoms 
entirely  mental.  The  patient  at  tirst  thought  he  was  at 
home,  failed  to  recognize  his  sister,  but  knew  his  own 
name.  On  the  fourth  day  he  was  motionless  and  speech- 
less unless  disturbed,  and  when  questioned  answered 
mechanically;  on  the  next  day  he  constantly  attempted  to 
get  out  of  bed  and  out  of  the  ward,  and  attacked  another 
patient  with  a  bottle;  and  on  the  day  following  he  was 
again  quiet  and  apathetic.  A  little  later  he  was  violently 
delirious  for  three  successive  nights,  but  was  afterward 
quiet  and  began  to  take  some  interest  in  what  went  on 
about  him ;  his  mind  became  less  confused  and  he  could 
remember  circumstances  immediately  preceding  his  hurt. 
He  was  until  the  fifth  week  unable  to  suggest  a  subject  of 
conversation,  or  to  connect  ideas,  and  he  laughed  much 
and  without  sufficient  cause.  At  a  later  period  his  mental 
condition  was  apparently  normal ;  a  slightly  weak  expres- 
sion of  face  only  remained. 

Case  CCLXXXV. — Female,  aged  seventeen  years,  fell 
three  stories  through  a  hatchway;  contusion  of  left  occipi- 
tal region ;  no  fracture  discovered  on  incision ;  general 
muscular  rigidity;  irritability  when  disturbed;  tempera- 
ture, 100.2°;  consciousness  not  fully  restored  upon  admis- 
sion to  the  hospital.  Noisy  delirium  began  on  the  fourth 
and  continued  till  the  ninth  day.  On  the  tenth  day  in- 
complete left  hemiplegia,   dilatation  of   left   pupil,  and   a 


CASES    UNVERIFIED    BY    NECROPSY.  573 

loss  of  faecal  and  urinary  control  which  continued  for  eight 
days.  The  paretic  condition  subsequently  improved,  and 
the  mental  condition  was  good,  when  an  attack  of  nostal- 
gia caused  the  patient's  removal  from  the  hospital.  The 
temperature  was  100.2°  on  admission,  and  was  ioo°-(-  for 
five  days,  99°+  for  five  days  and  then  became  normal ;  it 
rose  on  the  thirteenth  day  in  fourteen  hours  from  99°  to 
103.5°,  ^iid  in  the  next  twenty-four  hours  declined  to 
101°,  and  rose  to  104.5°,  and  was  for  two  days  from  102^ 
to  104°;  its  subsequent  range  was  from  101.4°  to  99.6°  to 
102°. 

Case  CCLXXXVI. — Male,  aged  thirty-three  years, 
fell  three  stories  and  struck  upon  the  right  side  of  his 
head,  causing  contusion  but  no  fracture.  On  admission 
to  the  hospital,  active  delirium,  and  dilatation  of  right 
pupil.  The  active  delirium  continued  for  eleven  days 
with  brief  daily  intermissions,  the  dilatation  of  the  right 
pupil  for  three  days,  and  loss  of  memory  and  faecal  con- 
trol for  two  days.  Facial  paralysis,  involving  both  upper 
and  lower  face  and  the  tongue,  was  observed  on  the 
eleventh  day  and  existed  when  patient  was  discharged 
from  the  hospital  on  the  thirty-third  day.  His  mental 
condition  was  normal  on  the  thirteenth  day,  though  some 
transitory  delusions  occurred  a  little  later.  The  highest 
temperature  was  on  the  first  day,  100.2°,  and  became 
normal  on  the  nineteenth  day.  The  pulse  never  exceeded 
100,  and  was  70  for  eight  days.  The  respiration  was  from 
18  to  20. 

Case  CCLXXXVII. — Female,  aged  fifty-seven  years, 
fell  one  flight  of  stairs  and  was  unconscious  for  five  min- 
utes. Wound  in  right  frontal  region,  no  fracture,  and  no 
general  symptoms ;  no  recollection  of  the  manner  of  in- 
jury for  twenty-four  hours;  stupor  through  the  third  day, 
and  subsequent  vertigo,  which  existed  at  the  time  of  the 
patient's  discharge  from  the  hospital  on  the  eighteenth 
day.  The  temperature  was  highest  on  the  second  day, 
100.2°,    and  was  normal   on   the   tenth    day.      The    right 


574  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

axillary  temperature  was  one  degree  higher  than  the  left 
from  the  sixth  to  the  ninth  days,  and  the  axillary  tem- 
peratures were  afterward  symmetrically  subnormal. 

Case  CCLXXXVIII.— Male,  aged  twenty-eight  years, 
thrown  from  a  truck  against  an  elevated-railway  pillar; 
loss  of  consciousness  for  fifteen  minutes,  and  after  an  in- 
terval of  thirty  minutes,  in  which  he  was  able  to  talk,  a 
recurrence  of  unconsciousness  which  was  permanent.  On 
admission  to  the  hospital  some  hours  later,  pupils  dilated, 
slipfht  muscular  contractions  in  left  extremities,  irrita- 
bility,  loss  of  urinary  control,  right  radial  pulsations  fuller 
and  stronger  than  the  left,  respiration  irregular,  tempera- 
ture of  99.4°,  and  a  little  later  contraction  of  the  left  pupil. 
Coma  became  profound,  pulse  increased  from  68  to  140, 
both  pupils  were  dilated,  the  face  became  cyanotic,  respi- 
ration momentarily  ceased  and  was  artificially  restored ; 
death  occurred  one  hour  later,  twenty-four  hours  after  ad- 
mission, the  respirations  having  been  three  in  the  minute. 
Temperature,  101.4°,  with  immediate  post-mortem  reces- 
sion. 

Case  CCLXXXIX.— Male,  aged  fourteen  years,  fell 
from  a  truck,  and  was  unconscious  for  thirty  minutes. 
On  admission  to  the  hospital,  stupor,  vomiting  of  a  dark 
brown  fluid;  temperature,  99°;  pulse,  100°;  respiration,  20. 
Second  and  third  days,  stupor  continued,  head  and  eyes 
turned  to  the  right,  posterior  cervical  muscular  rigidity, 
left  radial  pulse  much  stronger  than  the  right,  retention 
of  urine;  temperature,  99°  to  102.4°;  pulse,  78,  60,  72; 
respiration,  28-20.  Fourth  to  sixth  days,  mental  condition 
brighter,  cervical  rigidity  continued,  temperature,  101.6°, 
declining  to  98.6°;  pulse,  58-68;  respiration,  22-18. 
Seventh  day,  several  left  unilateral  convulsions  beginning 
in  the  upper  extremity  and  involving  the  face;  tempera- 
ture, 99.8°-99.6°  ;  loss  of  urinary  control  after  the  third  day. 
The  patient's  condition  became  normal  on  the  sixteenth  day, 
with  no  subsequent  symptoms;  convulsions  did  not  recur. 

Case    CCXC. — Male,    aged  fifty-three  years;    fell  and 


CASES    UXVERIFIED    BY    NECROPSY.  575 

Struck  his  head,  ^vas  dazed  for  a  few  moments,  walked 
home,  was  stupid  and  somnolent ;  lost  faecal  and  urinary 
control  from  the  first  day.  On  admission  to  hospital 
three  days  later,  no  external  injury  or  evidence  of  previous 
hemorrhage,  pupils  normal,  rigidity  of  right  side,  left 
subconjunctival  ecchymosis,  and  stupid  mental  condition; 
answered  "Yes"  to  all  questions.  On  the  following  day 
mental  condition  brighter,  but  no  speech ;  lack  of  faecal 
and  urinary  control  continued.  At  the  end  of  the  Aveek, 
patient  still  answered  "Yes"  to  all  questions  or  began  an 
irrelevant  answer  which  was  never  finished,  and  had  still 
lack  of  urinary  and  faecal  control,  with  a  slight  diminu- 
tion of  muscular  power  on  the  right  side.  In  the  second 
week,  there  Avere  no  symptoms  except  those  of  mental  dis- 
order. He  still  failed  to  complete  the  aswer  to  a  question 
if  it  were  more  than  the  usual  "  Yes"  ;  but  his  mental  proc- 
esses seemed  to  be  normal  and  his  facies  was  bright.  In 
the  third  week  he  answered  a  greater  number  of  questions 
intelligently,  though  many  still  incongruously  with  "Yes." 
He  indicated  some  slowness  of  comprehension,  often 
going  back  to  a  previous  question  in  framing  an  answer 
to  the  one  proposed.  He  recognized  his  family,  but  had 
forgotten  where  he  lived.  In  the  fourth  Aveek  he  Avas  out 
of  bed  and  ceased  to  ansAver  "Yes"  to  questions  in  general, 
but  under  the  mental  strain  of  attention  his  mind  often 
Avandered  and  he  Avas  inarticulate  or  incoherent.  He 
could  not  giA'e  his  address,  but  selected  the  right  one  out 
of  seA'eral  AA-hich  Avere  suggested.  His  facial  expression 
Avas  weak.  In  the  sixth  Aveek  he  seemed  rational  and  in- 
telligent, though  if  questioned  he  soon  broke  doAAm  and 
began  to  ansAver  "Yes"  at  random,  and  Avas  unable  to  tell 
where  he  lived.  His  facies  was  still  Aveak,  and  he  smiled 
too  much.  The  temperature  on  admission  Avas  99°,  and 
never  exceeded  that  degree ;  his  pulse  Avas  from  60  to  74, 
and  respiration  from  20  to  17.  His  head  was  shaved  soon 
after  admission,  and  a  contusion  then  discoA^ered  in  the 
left  parietal  region. 


5/6  INJURIES   OF   THE    BRAIN   AND    MEMBRANES. 

Case  CCXCI. — Male,  aged  eight  years,  fell  five  stories 
head  foremost  through  an  air  shaft,  and  struck  his  head 
upon  a  pile  of  paper ;  primary  unconsciousness,  and  con- 
vulsions while  in  the  ambulance.  On  admission  to 
hospital,  temperature,  97.4°;  pulse  and  respiration  slightly 
accelerated,  lacerated  wounds  above  the  right  orbit  and 
below  the  occipital  tuber,  pupils  normal,  and  great  rest- 
lessness. The  patient  during  the  first  week  was  stupid, 
heedless  of  questions,  resented  disturbance,  and  required 
mechanical  restraint.  His  mental  condition  then  became 
one  of  dementia;  his  manner  and  speech  were  silly  and  he 
wept  much ;  no  muscular  disorders  after  the  first  day,  and 
no  loss  of  faecal  or  urinary  control  at  any  time.  At  the 
end  of  a  month  there  was  no  further  evidence  of  mental 
derangement,  but  there  was  a  drawl  in  his  speech.  The 
temperature  rose  to  ioi°-|-'  ^'^^  afterward  varied  from 
98.6  to  99°;  pulse  and  respiration  were  moderately  accel- 
erated. The  child  before  his  injury  was  of  more  than 
ordinary  intelligence,  as  was  indicated  by  his  mental  con- 
dition after  recovery. 

Case  CCXCII.— Male,  aged  fifty-three,  stabbed  him- 
self with  a  penknife  through  an  existent  trephine  open- 
ing. Eight  years  previously  he  had  been  struck  upon  the 
head  by  a  heavy  piece  of  timber,  and  had  subsequently 
suffered  from  left  unilateral  convulsions,  which  occurred  at 
two-weeks  intervals.  Two  years  later  he  was  trephined  at 
two  points  in  the  right  parietal  bone,  anteriorly  and  pos- 
teriorly, near  the  median  line,  for  their  relief,  but  they 
afterward  increased  in  frequency  and  severity.  In  a  fit  of 
rage  and  despondency  he  stabbed  himself  with  a  knife 
blade  one-half  inch  in  width  and  two  inches  in  length, 
through  the  cutaneous  and  membranous  coverings  of  the 
anterior  osseous  wound.  On  immediate  admission  to  the 
hospital,  incomplete  facial  paralysis  and  complete  paralysis 
of  the  left  side,  with  muscular  rigidity,  loss  of  urinary  con- 
trol, and  loss  of  patellar  reflex  ;  mental  condition  apathetic, 
and  attention  fixed  with  difficulty;  nutrition  bad,  and  gen- 


CASES    UNVERIFIED    BY    NECROPSY.  577 

era]  condition  weak;  temperature,  99.4°;  pulse,  120; 
respiration,  20.  The  wound  closed  by  primary  union, 
urinary  control  was  regained,  convulsions  did  not  recur; 
the  left  elbow  was  flexed  and  the  left  fingers  contracted 
when  he  left  the  hospital  in  the  eighth  week.  Tempera- 
ture did  not  exceed  ioo°-|-. 

INTRACRANIAL     LESION      FROM     PISTOL-SHOT 
WOUNDS   WITH    RECOVERY. 

Case  CCXCIII. — Male,  aged  twenty-eight  years,  shot 
himself  in  the  right  temporal  region,  using  all  five  barrels 
of  a  pistol  of  0.22  cal.  All  the  bullets  entered  a  space 
one  inch  in  diameter  just  behind  and  a  little  above  the 
right  external  angular  process.  Each  wound  was  distinct, 
and  apparently  made  at  contact,  as  there  were  no  burns  or 
traces  of  powder  upon  the  surface.  External  hemorrhage 
was  profuse,  but  there  were  no  shock  and  no  general 
symptoms.  Two  bullets  were  removed  from  the  cutane- 
ous wounds,  and  one  from  the  masseter  muscle,  into  which 
it  had  been  deflected.  One  bullet  was  undiscovered,  and 
one  only  penetrated  the  cranium  and  was  lodged  at  some 
distant  and  unknown  point  between  it  and  the  dura  mater, 
which  was  uninjured.  There  were  no  subsequent  symp- 
toms. 

Case  CCXCIV. — Bullet  of  0.32  cal.  External  wound 
one  inch  above  the  right  zygoma;  considerable  hemor- 
rhage externally  and  beneath  the  conjunctiva;  so  much 
protrusion  of  the  eye  that  the  lids  could  not  be  closed; 
entire  loss  of  sight  and  muscular  control.  The  wound  was 
enlarged  by  crucial  incision,  and  the  skull  trephined. 
The  bullet  was  then  detected  by  an  ordinary  probe,  near 
the  right  orbital  plate;  the  eye  was  removed,  the  fissured 
bone  sufficiently  chiselled  away,  the  dura  mater  incised, 
and  the  ball  extracted  from  the  cerebral  cortex  at  the 
margin  of  the  optic  foramen.  The  wound  was  drained  by 
tube  for  two  weeks,  and  the  patient  when   discharged  at 

37 


578  INJURIES    OF   THE   BRAIN   AND    MEMBRANES. 

the  end  of  two  months  was  apparently  entirely  well.  The 
only  symptoms  succeeding  operation  were  delirium  for 
two  days,  and  headache. 

Case  CCXCV. — External  wound  one  inch  above  right 
zygoma;  eye  removed  by  operation,  as  sight  was  de- 
stroyed, and  patient  transferred  to  Bellevue  Hospital  one 
week  later.  The  ball  was  detected  beneath  the  mucous 
membrane,  just  above  the  alveolar  process  of  the  right 
superior  maxilla  and  removed ;  no  subsequent  symptoms. 

Case  CCXCVI. — External  wound  above  right  frontal 
sinus;  calibre  of  ball,  0.38;  range,  eighteen  inches; 
smoke  area  of  one-half  inch ;  powder  grains  embedded  in 
an  area,  size  not  noted.  The  patient  was  knocked  down 
by  the  concussion,  but  did  not  lose  consciousness;  walked 
to  the  hospital ;  no  general  symptom  except  frontal  head- 
ache. The  external  table  was  fissured  in  all  directions; 
the  bullet  was  lodged  in  and  below  the  inner  table,  with  its 
apex  penetrating  the  dura  but  not  wounding  the  brain, 
and  was  removed,  included  in  a  button  of  bone.  No  sub- 
sequent symptoms. 

Case  CCXCVII. — External  wound  at  inner  canthus  of 
right  eye;  calibre  of  ball,  0.32;  range,  eight  to  ten  feet; 
no  loss  of  consciousness  or  of  vision ;  hemorrhage  from 
the  nose.  An  exploration  of  its  track  did  not  reveal  the 
ball,  but  led  to  the  opinion  that  it  was  located  in  the  body 
of  the  sphenoid  bone.  Violent  delirium,  which  was  re- 
garded as  a  secondary  alcoholic  mania,  supervened,  and 
continued  for  several  days.  There  were  no  subsequent 
symptoms  and  no  further  attempt  was  made  to  determine 
the  location  of  the  bullet. 

Case  CCXCVIII. — External  wound  one  and  one-half 
inches  above,  and  one-half  inch  in  front,  of  right  ear;  ad- 
mitted to  Bellevue  Hospital  four  days  after  the  reception 
of  injury ;  smoke  stain  still  visible  upon  the  ear,  and  ten 
or  twelve  grains  of  powder  embedded  in  its  surface.  An 
incision  of  the  wound  had  been  made  at  another  hospital ; 
the  temporal  muscle  and  the  bone  about  the  bullet  open- 


CASES   UNVERIFIED    BY    NECROPSY.  579 

ing-  was  powder  stained;  osseous  wound  circular  and 
larger  than  the  ball,  which  was  of  0.32  cal.  There 
had  been  loss  of  urinary  control  for  two  or  three  days,  but 
none  was  observed  after  admission  to  Bellevue ;  no  motor 
or  sensory  disturbance.  Temperature,  100°;  pulse,  92; 
respiration,  20. 

Case  CCXCIX. — Female,  aged  twenty-eight  years; 
pistol-shot  wound  through  right  temporal  region,  inflicted 
during  a  paroxysm  of  suicidal  mania;  ball  of  32  calibre; 
primary  unconsciousness.  On  admission  three  hours  later 
no  general  symptoms;  wound  of  entrance,  half  an  inch 
posterior  to  right  external  angular  process,  Y-shaped, 
three-quarters  of  an  inch  in  length  in  each  of  its  arms; 
surface  powder  stained ;  some  grains  of  powder  embedded 
in  the  substance  of  the  temporal  muscle,  but  none  in  the 
skin ;  profuse  hemorrhage  had  occurred  from  the  wound 
and  still  continued  from  the  mouth  and  nose ;  bullet  en- 
trance through  the  bone  small  and  circular,  and  covered 
by  a  valve  of  muscular  tissue.  On  examination  the  pa- 
tient was  fully  conscious,  rational,  and  self-possessed.  The 
right  eye  was  swollen,  the  lids  were  ecchymotic,  and  vision 
on  that  side  was  entirely  lost.  The  ball  had  passed  from 
the  temporal  fossa  beneath  the  lesser  wing  of  the  sphenoid 
and  through  the  floor  of  the  middle  fossa  at  the  margin 
of  the  sphenoid  body.  The  track  was  easily  followed 
through  the  anterior  cerebral  lobe,  and  the  bony  margin 
of  exit  could  be  defined  by  slightly  opening  the  blades  of 
the  short  bullet  forceps  which  had  been  inserted.  A 
small  portion  of  brain  matter,  not  larger  than  a  pea,  es- 
caped from  the  eternal  wound.  On  the  following  day  she 
was  rather  stupid,  and  another  trivial  amount  of  brain 
matter  was  extruded.  On  the  third  day  the  left  eyelids 
became  moderately  ecchymotic  and  the  right  side  of  the 
face  and  neck  much  swollen  and  painful.  There  were 
convulsive  movements  of  the  hands  and  feet,  and  a  loss  of 
smell  in  the  right  nostril  was  confirmed  by  careful  exam- 
ination.    On  the  fourth  day  she  was  quiet  and  somnolent. 


580  INJURIES    OF   THE    BRAIN   AND    MEMBRANES. 

and  bad  some  headache.  The  left  side  of  the  mouth  was 
drawn  a  little  upward  and  tenderness  existed  behind  the 
left  ear.  On  the  fifth  day  somnolence  and  headache 
ceased,  pain  and  swelling  of  the  right  side  of  the  face  and 
neck  diminished,  and  the  mental  condition  became 
brighter.  On  the  tenth  day  she  was  restless  and  began  to 
suffer  pain  on  the  right  side  of  the  head,  which  on  the 
succeeding  day  was  intense.  The  eye  became  more  vas- 
cular, swollen,  and  prominent,  and  on  the  fourteenth  day 
was  extirpated  under  ether.  At  the  end  of  a  month  the 
bullet  wound  of  entrance  had  become  simply  cutaneous 
and  was  in  process  of  cicatrization.  The  swelling  of  the 
right  side  of  the  face  and  neck  and  the  tenderness  behind 
the  left  ear  had  ceased  to  exist.  The  pain  on  the  right 
side  of  the  head,  which  persisted  in  some  degree,  was  no 
longer  constant  or  the  source  of  any  considerable  discom- 
fort. There  had  been  no  indication  of  any  form  of  mental 
impairment  at  any  time  since  the  slight  hebetude  on  the 
second  and  third  days  after  the  reception  of  injury,  and 
no  loss  of  faecal  or  urinary  control. 

The  temperature  on  admission  was  ioo°;  rose  to  102.4° 
in  twelve  hours,  and  declined  to  99.8°  on  the  second  day, 
and  then  varied  from  101°-)-  to  99°+  till  the  twelfth  day; 
it  did  not  exceed  100°  after  the  fifteenth  day  and  was  sub- 
sequently from  99°  to  100°.  The  right  axillary  tempera- 
ture was  habitually  two-tenths  of  a  degree  higher  than  the 
left.  The  pulse  was  from  72  to  80  till  the  third  day,  from 
68  to  52  till  the  twelfth  day,  and  subsequently  from  70  to 
78.  The  respiration  was  28  on  admission  and  afterward 
normal — 16  to  22. 

In  the  sixth  week  the  wound  had  healed  and  there 
were  no  symptoms.  At  the  end  of  three  months  her 
mental  and  physical  condition  was  normal — in  her  own 
opinion  better  than  before  the  injury  was  received.  One 
year  later  the  recurrence  of  her  malady  necessitated  a  re- 
turn to  an  as^'lum  for  the  insane. 

Case  CCC. — Male,  aged  thirty  years,  transferred  from 


CASES    UNVERIFIED    BY    NECROPSY.  58 1 

another  hospital  two  weeks  after  the  infliction  of  a  suicidal 
pistol-shot  wound  of  the  head ;  ball  said  to  have  been  of 
small  calibre.  A  wound,  one  inch  in  length,  existed  one 
inch  above  the  right  external  angular  process,  which  was 
then  nearly  closed  by  granulations,  but  through  which  a 
cranial  opening  could  be  detected ;  pupils  contracted ; 
radial  pulsations  symmetrical ;  diplopia,  and  internal  stra- 
bismus of  both  eyes ;  perceptible  weakness  of  the  muscles 
of  the  left  arm;  burning  and  tingling  sensations  in  left 
leg;  all  reflexes  normal;  mental  condition  apathetic  with 
some  slowness  of  comprehension.  Ten  days  later,  in- 
ternal strabismus  and  diplopia  had  disappeared,  while 
paretic  condition  of  the  muscles  of  the  left  arm  had  in- 
creased and  extended  to  the  pectoral  muscles  and  to  the 
extensors  of  the  forearm.  The  flexor  muscles  of  the 
fingers  of  the  left  hand  were  also  involved,  and  the  exten- 
sor muscles  of  the  left  thigh  were  weakened  and  painful. 
He  was  discharged  from  the  hospital  at  the  end  of  the  third 
week  after  admission  without  appreciable  change  in  his 
condition.  The  temperature  had  varied  from  100.6°  to 
98.4°;  pulse,  96-68;  respiration,  24  to  18. 

This  patient  was  re-admitted  to  Bellevue  Hospital  six 
months  later.  In  the  mean  time  he  had  been  subjected  to 
the  action  of  the  Rontgen  rays  as  a  means  of  discovering 
the  position  of  the  bullet,  with  the  result  noted  in  a  subse- 
quent chapter.  At  this  time  the  paralysis  of  the  left  side 
had  increased  with  contraction  of  the  fingers  and  of  the 
elbow-joint.  His  mental  condition  was  one  of  pronounced 
dementia  with  paroxysms  of  acute  mania.  The  occiput, 
which  had  been  shaved  for  exposure  to  the  rays,  was  still 
entirely  denuded  of  hair,  and  the  hair  bulbs  were  appar- 
ently destroyed. 


582  INJURIES    OF   THE   BRAIN    AND    MEMBRANES. 


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its  patholog}'  in  the  same  treatise.  It  enables  the  surgeon  to  refer  to  both  branches  of 
the  subject  without  loss  of  time,  and  each  serves  to  accentuate  the  importance  of  the 
other.  Not  since  Billroth's  classic  treatise  on  surgical  pathology,  that  appeared  some 
twenty-three  years  ago,  has  there  been  a  more  satisfactory  exposition  of  surgical 
pathology  than  here  given  by  Tillmanns.  It  is  brought  down  to  the  immediate  present 
under  the  light  afforded  by  the  most  modern  researches  in  bacteriology.  A  student 
should  be  taught  pathology  before  he  is  instructed  in  surgical  diseases  and  injuries. 
These  latter  he  will  then  understand  with  a  clearness  that  could  not  be  possible  if  the 
method  of  teaching  were  reversed.  The  editor  and  the  translators  appreciating  this 
fact  have  duly  emphasized  it  in  bringing  out  and  makirg  available  as  a  text-book  one 
of  the  best  treatises  on  the  principles  of  surgery  and  suigical  pathology  that  has  yet 
been  written.  It  is  impossible  in  the  space  now  at  our  disposal  for  us  to  do  more  than 
express  our  opinion  of  this  excellent  work  and  to  commend  it  to  student  and  practi- 
tioner as  a  safe  and  scientific  guide,  which  we  do  here  and  now." — Buffalo  Medical 
and  Surgical  Journal. 

"It  is  strange  that  this  excellent  work  has  been  allowed  to  pass  to  a  third  edition 
in  German,  without  a  translation  in  English  until  this  time.  The  arrangement  of 
the  book  is  different  from  that  of  the  average  text-book  on  the  subject.  It  is  divided 
into  three  sections  :  First,  General  Principles  governing  Surgical  Operations  ;  second, 
Methods  of  applying  Surgical  Dressings  ;  and  third.  Surgical  Pathology  and  Therapy. 
The  work  of  translators  and  editor  has  been  excellently  done.  The  book  is  printed 
and  bound  in  the  correct  and  elegant  style  for  which  the  publishers  are  noted.  The 
work  is  strictly  modern,  and  none  of  the  recent  advances  in  surgical  pathology  have 
been  left  unconsidered." — Chicago  Medical  Recorder. 

"  It  is  just  the  book  for  surgeons  who  entered  practice  before  surgical  bacteriology 
had  been  developed  so  as  to  afford,  as  it  now  does,  a  firm  foundation  for  the  best 
clinical  work.  By  its  aid  one's  knowledge  of  the  results  of  most  recent  investigations 
can  be,  so  to  speak,  brought  up  to  date.  No  surgeon,  however  experienced,  can  read 
it  without  having  his  technique  consciously  or  unconsciously  improved,  and  his  grasp 
upon  the  fixed  facts  of  surgical  science  made  more  secure.  In  illustrations,  type, 
paper,  and  binding,  Tillmanns's  '  Surgical  Pathology'  is  up  to  the  Appleton  standard, 
and  that  standard,  as  we  all  know,  is  unsurpassed." — Canada  Lancet. 


New  York :  D.  APPLETON  &  CO.,  72  Fifth  Avenue. 


August,  1897. 

MEDICAL 

AND 

HYGIENIC    WOEKS 


PUBLISHED    BY 


D.  APPLETON  &  CO.,  72  Fifth  Avenue,  New  York 


AULDE  (JOHN).  The  Pocket  Pharmacy,  with  Therapeutic  Index.  A  resume 
of  the  Clinical  Applications  of  Eemedies  adapted  to  the  Pocket-case,  for 
the  Treatment  of  Emergencies  and  Acute  Diseases.     12mo.     Cloth,  $2.00. 

BARKER  (TOEDYCEj.  On  Sea-Sickness.  A  Popular  Treatise  for  Travelers 
and  the  General  Reader.     Small  12mo.     Cloth,  75  cents. 

BARKER  (FORDTCE).  On  Puerperal  Disease.  Clinical  Lectures  delivered  at 
Bellevue  Hospital.  A  Course  of  Lectures  valuable  alike  to  the  Student  and 
the  Practitioner.     Third  edition.     8vo.     Cloth,  $5.00 ;  sheep,  $6.00. 

BARTHOLOW  (ROBERTS).  A  Treatise  on  Materia  Medica  and  Therapeutics. 
Ninth  edition.  Revised,  enlarged,  and  adapted  to  "  The  Xew  Pharmacopoeia." 
8vo.     Cloth,  $5.00 ;  sheep,  $6.00. 

BARTHOLOW  (ROBERTS).  A  Treatise  on  the  Practice  of  Medicine,  for  the 
Use  of  Students  and  Practitioners.  Seyenth  edition,  revised  and  enlarged. 
8vo.     Cloth,  $5.00  ;  sheep,  $6.00. 

BARTHOLOW  (ROBERTS).  On  the  Antagonism  between  Medicines  and  be- 
tween Remedies  and  Diseases.  Being  the  Cartwright  Lectures  for  the  Tear 
1880.     8vo.     Cloth,  $1.25. 

BASTIAN"  (H.  CHARLTON).  Paralyses :  Cerebral,  Bulbar,  and  Spinal.  A 
Manual  of  Diagnosis  for  Students  and  Practitioners.  With  136  Illustra- 
tions.    Small  8vo,  671  pages.     Cloth,  $4.50. 

BASTIAN  (H.  CHARLTON)-  Paralysis  from  Brain  Disease  in  its  Common 
Forms.     With  Illustrations.     12mo,  3-40  pages.     Cloth,  $1.75, 

BILLINGS  (F.  S.).  The  Relation  of  Anunal  Diseases  to  the  Public  Health,  and 
their  Prevention.     8vo.     Cloth,  $4.00. 

BILLROTH  (THEODOR).  General  Surgical  Pathology  and  Therapeutics.  A 
Text-Book  for  Students  and  Physicians.  Translated  from  the  tenth  German 
edition,  by  special  permission  of  the  author,  by  Charles  E.  Hackley,  M.  D. 
rifth  Ameritan  edition,  revised  and  enlai^ed.     8vo.     Cloth,  $5.00;  sheep,  $6.00. 

BOYCE  (RUBERT).  A  Text-Book  of  Morbid  Histologry.  For  Students  and 
Practitioners.     "VTith  130  Colored  Illustrations.     Cloth,  $7.50. 

BRAMWELL  (BYROM).  Diseases  of  the  Heart  and  Thoracic  Aorta.  Illus- 
trated with  226  TVood-Engravings  and  68  Lithograph  Plates — showing  91 
Figures— in  all  317  Illustrations,     8vo.     Cloth,  $8.00;  sheep,  $9.00. 

BRYANT  (JOSEPH  D.),  A  Manual  of  Operative  Surgery.  Xew  edition,  rcTised 
and  enlarged.     793  Illustrations,     Bvo.     Cloth,  $5.00  ;  sheep,  $6.00. 

BURT  (STEPHEN  S.).  Exploration  of  the  Chest  in  Health  and  Disease.  8vo. 
210  pages.     With  Illustrations.     Cloth,  $1.50. 


CAMPBELL  (F.  R.).  The  Language  of  Medicine.  A  Manual  giving  the  Origin, 
Etymology.  Pronunciation,  and  Meaning  of  the  Technical  Terras  foond  in 
Medical  Literature.     8vo.     Cloth,  $3.00. 

CAEMICHAEL  (JAMES).  Disease  in  Children.  A  Manual  for  Students  and 
Practitioners.  Illustrated  with  Thirty-one  Charts.  12mo,  591  pages. 
(Stcoents'  Sebies.)     Cloth,  $3.00. 

CHAUVEAU  (A.).  Tlie  Comparative  Anatomy  of  the  Domesticated  Animals. 
Revised  and  enlarged,  witli  the  co-operation  of  S.  Arloing,  Director  of  the 
Lyons  Veterinary  School.  Secrmd  Lngli>b  edition.  Translated  and  edited 
by  George  f  leminp,  C.  B.,  LL.  D.,  F.  R.  C.  Y.  S.,  late  Principal  Veterinary 
Surgeon  of  the  British  Army;  Foreign  Corresponding  Member  of  the 
Si>ci6t6  Rt.yale  de  Medecine,  and  of  the  Soci6i6  Royale  de  M^decine  Pub- 
lique,  of  Belgium,  etc     Svd,  1084  pages, with  585  Illustrations.    Cloth,  $7.00. 

CORMIXG  (J.  L.).  Brain  Exhaustion,  with  some  Preliminai-y  Considerations 
on  Cerebral  DynacLics.     Crown  8vo.     Cloth,  $2.00. 

COR.'s  ING  (J.  L.).  Local  Anaesthesia  in  General  Medicine  and  Surgery.  Being 
the  Practical  Application  of  the  Author's  Recent  Discoveries.  With  Illus- 
trations.    Small  8vo.     Cloth,  $1.25. 

DAVIDSON    (ANDREW).      Geographical  Pathology:    An  Inquiry  into  the 

Geograpliical    Distribution  of  Infective    and    Climatic    Diseases.     2  vols. 

8vo.     Cloth,  $7.00. 
DEN(>U  (E.  B.).     Dii-eases  of  the  Ear.     A  Text-Book  for  Practitioners  and 

Students  of  Medii-ine.     With  ti  Colored  Plates  and  152  Illustrations  in  the 

text.     8vo.     Cloth,  $5.00;  sheep,  $6.00. 

DEXTER  (FRANKLIN).  The  Anatomy  of  the  Peritonaeum.  12mo.  With 
39  colored  Illustrations.     Cloth,  $1.50. 

DOTY  (ALVA II  li.).  A  Manual  of  Instruction  in  the  Principles  of  Prompt 
Aid  to  the  Injured.  Includmg  a  Chapter  on  Hygiene  and  the  Drill  Regula- 
tions tor  the  Hospital  Corps,  U.S.  A.  LesigiitU  fdr  Military  and  Civil  Use. 
Second  edition,  re\ised  and  eularged.     12mo,    121  Illustrations.     Cloth,  $1.50. 

ELLIOT  (GEORGE  T.).  Obstetric  Clinic:  A  Practical  Contribution  to  the  Study 
ol  Obstetrics  aud  the  D1^eases  of  Women  and  Children.    8vo.    Cloth,  $4.50. 

EVANS  (GEORGE  A.).  Hand-Book  of  Historical  and  Geographical  Phthisi- 
ology.  With  Special  Reference  to  the  Distribution  of  Cousumptiun  in  the 
Lmted  Stales.     8vo.     Cloth,  $2.00. 

EWALD  (C.  A.;.  Lectures  on  the  Diseases  of  the  Stomach.  By  Dr.  C.  A. 
Ewald,  Professor  of  Pathology  and  Tfierapeutics  in  the  University  ot  Berlin, 
etc.  Translated  from  tlie  German  by  special  permission  of  the  autiior,  by 
Morris  Manges,  A.M.,  M.  D.  Second  euilion,  reused  and  rearranged.  Clutli, 
$5.00 ;  sheep,  $0.00. 

FLINT  (AUSTIN).  Medical  Ethics  and  Etiquette.  Commentariee  on  the 
NatiuLal  Code  of  Ethics.     12iijO.     Cloth,  bO  cents. 

FLINT  (AUSTIN).  Medicine  of  the  Future.  An  Address  prepared  for  the 
Annual  Meeting  ot  the  British  Medical  Association  in  1866.  With  Portrait 
ot  Dr.  Hint.     12mo.     Cloth,  $1.00. 

FLINT  (AUSTIN,  Jr.).  Text-Book  ot  Human  Physiology;  designed  for  the 
Use  of  PraciiLioners  and  Students  of  Medicine.  Illustrated  \\ith  three 
hundred  and  sixteen  Woodcuis  and  Two  Plates.  Fonrtd  edition,  revised. 
Imperial  ??vo.     Cloth,  $6.00;  sheep,  $7.00. 

FLINT  (AUSITN,  Jr.).  The  Physiological  Effects  of  Severe  and  Protracted 
Muscular  Exercise;  wiih  Specinl  Reterence  to  its  intiuence  upon  the  Excre- 
tion of  Nitrogen.     12mo.     Cloth,  $1.00. 


FLINT  (AUSTIN,  Je.).  The  Source  of  Muscular  Power.  Arguments  and  Con- 
clusions drawn  from  Observation  upon  the  LIuman  Subject  under  Conditions 
of  Rest  and  of  Muscular  Exercise.     12mo.     Cloth,  $1.00, 

FLINT  (AUSTIN,  Je.).     Physiology  of  Man.     Designed  to  represent  the  Exist- 
ing State  of  Physiological  Science  as  applied  to  tlie  Functions  of  tlie  Human 
Body.     Complete  in  5  vols.,  8vo.     Per  vol.,  cloth,  $4.50  ;  sheep,  $5.50. 
*^*  Vols.  1  and  II  can  be  had  in  cloth  and  sheep  binding;  Vol.  Ill  in  sheep 
only.     Vol.  IV  is  at  present  out  of  print. 

FLINT  (AUSTIN,  Je.).  Manual  of  Chemical  Examinations  of  the  Urine  in 
Disease;  with  Brief  Directions  for  the  Examination  of  the  most  Common 
Varieties  of  Urinary  Calculi.     Revised  edition.     12mo.     Cloth,  $1.00. 

FOSTER  (FRANK  P.).  Illustrated  Encyclopssdic  Medical  Dictionary:  Being 
a  Dictionary  of  the  Technical  Terms  used  by  Writers  on  Meilicine  and  the 
Collateral  Sciences  in  the  Latin,  English,  French,  and  German  Languages. 
The  work  consists  of  Four  Volumes,  and  is  sold  in  Parts;  Three  Parts  to 
a  Volume.     (Sold  only  by  subscription.) 

FOSTER  (FRANK  P.).  A  Reference-Book  of  Practical  Therapeutics,  by 
various  writers.  In  Two  Volumes.  Edited  bv  Frank  P.  Foster,  M.  D., 
Editor  of  The  New  York  Medical  JournaL  Vol.  I.  Cloth,  $5  00;  sheep, 
$6  00;   half  morocco,  $6.50.     (Sold  only  by  subscription.) 

FOURNIER  (ALFRED).  Syphilis  and  Marriage.  Translated  by  P.  Albert 
Morrow,  M.  D.     8vo.     Cloth,  $2.00;  sheep,  $3.00. 

FREY  (HEINRICH).  The  Histology  and  Histochemistry  of  Man.  A  Treatise 
on  the  Elements  of  Composition  and  Structure  of  the  Human  Body.  Trans- 
lated from  the  fourth  German  edition  by  Arthur  E.  J.  Barker,  M.  D.,  and 
revised  by  the  author.  "With  608  Engravings  on  Wood.  8vo.  Cloth,  $5.00, 
sheep,  $6.00. 

FRIEDLANDER  (CARL).  The  Use  of  the  Microscope  in  Clinical  and  Patho- 
h)gica]  Examinations.  Second  edition,  enlarged  and  trapioved,  with  a 
Chroraolithogiaph  Plate.  Translated,  with  the  permission  of  tiie  author, 
by  Henry  0.  Coe,  M.  D.     8vo.     Cloth,  $i.00. 

FUCHS  (ERNEST).  Text-Book  of  Ophthalmology.  By  Dr.  Ernest  Fuchs, 
Professor  of  Ophthalmology  in  the  University  of  Vienna.  With  178  Wood- 
cuts. Authorized  translation  from  the  second  enlarged  and  improved  Ger- 
man editiun,  by  A.  Duane,  M.  D.     Cloth,  $5.00;  shee]),  $6.00. 

GARMANY  (JASPER  J.).  Operative  Surgery  on  the  Cadaver.  With  Two 
Colored  Diagrams  showing  the  Collateral  Circulation  after  Ligatures  of 
Arteries  of  Arm,  Abdomen,  and  Lower  Extremity.  Small  8vo.  Cloth, 
$2.00. 

GERSTER  (ARPAD  G.).  The  Rules  of  Aseptic  and  Antiseptic  Surgery. 
A  Practical  Treatise  for  the  Use  of  Students  and  the  General  Practitioner. 
Illustrated  with  over  two  hundred  hue  Engravings.  8vo.  Cloth,  $5.00; 
sheep,  $6.00. 

GIBSON-RCSSELL.  Physical  Diagnosis:  A  Guide  to  Methods  of  Clinical  In- 
vestigation. By  G.  A.  Gibson,  M.  D.,  and  William  Russell,  M.D.  With 
101  Illustrations.     12mo.     (Student's  Series.)     Cloth,  $2.50. 

GOULEY  (JOHN  W.  S.).  Diseases  of  the  Urinary  Apparatus.  Part  L  Phleg- 
masic  Affections.  Being  a  Series  of  Twelve  Lectures  delivered  during  the 
autumn  of  1891.  With  an  Addendum  on  Retention  of  Urine  from  Pros- 
tatic Obstruction  in  Iiklerly  Men.     Cloth,  $1.50. 

GROSS  (SAMUEL  W,).  A  Practical  Treatise  on  Tumors  of  the  Mammary 
Gland.    Illustrated.    Svo.    Cloth,  $2.50. 


GRUBER  (JOSEF).  A  Text-Book  of  the  Diseases  of  the  Ear.  Translated 
from  the  second  German  edition  by  special  permission  of  the  author,  and 
edited  by  Edward  Law,  M.  D.,  and  Coleman  Jewell,  M.  D.  With  165  Illus- 
trations and  70  Colored  Figures  on  Two  Lithographic  Plates.  8vo.  Cloth, 
$6.50     sheep,  $7.50. 

GUTMANN  (EDWARD).  The  Watering-Places  and  Mineral  Springs  of  Ger- 
many, Austria,  and  Switzerland.     Illustrated.     12rao.     Cloth,  $2.50. 

HAMMOND  (W.  A.).  A  Treatise  on  Diseases  of  the  Nervous  System.  With 
the  Collaboration  of  Graeme  M.  Hammond,  M.  D.  With  One  Hundred  and 
Eighteen  Illustrations.  IVinth  edition,  with  corrections  and  additions.  8vo. 
Cloth,  $5.00 ;  sheep,  $6.00. 

HAMMOND  (W.  A.).  A  Treatise  on  Insanity,  in  its  Medical  Relations.  8vo. 
Cloth,  $5.00;  sheep,  $6.00. 

HAMMOND  (W.  A.).  Clinical  Lectures  on  Diseases  of  the  Nervous  System. 
Delivered  at  Bellevne  Hospital  Medical  College.  Edited  by  T.  M.  H.  Cross, 
M.  D.     Svo.     Cloth,  $3.50. 

HARVEY  (A.).     First  Lines  of  Therapeutics.     12mo.     Cloth.  $1.50. 

HIRT  (LUDWIG).  The  Diseases  of  the  Nervous  System.  A  Text-Book  for 
Physicians  and  Students.  Translated,  with  permission  of  the  Auth(jr,  by 
August  Hoch,  M.D.,  assisted  by  Frank  R.  Smith,  A.M.  (Cantab.),  M.  D., 
Assistant  Physicians  to  the  Johns  Hopkins  Hospital.  With  an  Introduc- 
tion by  William  Osier,  M.  D.,  F.  R.  C.  P.,  Professor  of  Medicine  in  the  Johns 
Hopkins  University,  and  Physician-in-Chief  to  the  Johns  Hopkins  Hospital, 
Baltimore.  Svo,  671  pages.  With  178  Illustrations.  Cloth,  $5.00  ;  sheep, 
$6.00. 

HOFFMANN-ULTZMANN.  Analysis  of  the  Urine,  with  Special  Reference 
to  Diseases  of  the  Urinary  Apparatus.  By  M.  B.  Hoffmann,  Professor  in 
the  University  of  Gratz,  and  R.  Ultzmann,  Tutor  in  the  University  of 
Vienna.    Tliird  edition,  revised  and  enlarged.     8vo.     Cloth,  $2.00. 

HOLT  (L.  EMMETT).  The  Diseases  of  Infancy  and  Childhood.  Svo.  Cloth, 
$6.00 ;  sheep,  $7.00 ;  half  morocco,  $7.50.     (Sold  only  hy  subscription.) 

HOLT  (L.  EMMETT).  The  Care  and  Feeding  of  Children.  A  Catechism  for 
the  Use  of  Mothers  and  Children's  Nurses.     16mo.     Cloth,  50  cents. 

HOWE  (JOSEPH  W.).  Emergencies,  and  how  to  treat  them.  Fourth  edition, 
revised.     Svo.     Cloth,  $2.50. 

HOWE  (JOSEPH  W.).  The  Breath,  and  the  Diseases  which  give  it  a  Fetid 
Odor.  With  Directions  for  Treatment.  Second  edition,  revised  and  corrected. 
12mo.     Cloth,  $1.00. 

SUEPPE  (FERDINAND).  The  Methods  of  Bacteriological  Investigation. 
Written  at  the  request  of  Dr.  Robert  Koch.  Translated  by  Hermann  M. 
Biggs,  M.D.     Illustrated.     Svo.     Cloth,  $2.50. 

JACCOUD  (S.).  The  Curability  and  Treatment  of  Pulmonary  Phthisis.  Trans- 
lated and  edited  by  Montagu  Lubbock,  M.  D.     Svo.     Cloth,  $4.00. 

KEYES  (E.  L.).  A  Practical  Treatise  on  Genito-Urinary  Diseases,  including 
Syphilis.  Being  a  new  edition  of  a  work  with  the  same  title  by  Van  Buren 
and  Keyes.  Almost  entirely  rewritten.  Svo.  With  Illustrations.  Cloth, 
$5.00;  sheep,  $6.00. 

KEYES  (E.  L.).  The  Tonic  Treatment  of  Syphilis,  including  Local  Treatment 
of  Lesions,     Second  edition.     Svo.     Cloth,  $1.00. 


KINGSLET  (N.  W.).  A  Treatise  on  Oral  Deformities  as  a  Branch  of  Mechan- 
ical Surgery.    With  over  350  Illustrations.    8vo.   Cloth,  $5.00;  sheep,  $6.00. 

LEGG  (J.  WICKHAM).  On  the  Bile,  Jaundice,  and  Bilious  Diseases.  With 
Illustrations  in  ChromolithograpliT.     8vo.      Cloth,  $6.00 ;  sheep,  $T.OO. 

LITTLE  (W.  J.).  Medical  and  Surgical  Aspects  of  In-Knee  (Genu- Valgum) : 
Its  Relation  to  Rickets,  its  Prevention,  and  its  Treatment,  with  and  without 
Surgical  Operation.  Illustrated  by  upward  of  Fifty  Figures  and  Diagrams. 
8vo.     Cloth,  $2.00. 

LORING  (EDWARD  G.).    A  Text-Book  of  Ophthalmoscopy. 

Part  I.  The  Normal  Eye,  Determination  of  Refraction,  and  Diseases  of  the 
Media.  With  131  Illustrations,  and  4  Chromolithographs.  8vo.  Buck- 
ram, $5.00. 

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author  finished  just  prior  to  his  death,  has  been  thoroughly  edited  and 
revised  by  F.  B.  Loring,  M.D.,  of  Washington,  D.  C,  and  is  now  issued 
in  the  same  style  as  the  first  volume.  Profusely  illustrated.  Part  II, 
buckram,  $5.00.     Two  Parts,  buckram,  $10.00. 

LUSK:  (WILLIAM  T.).  The  b'cience  and  Art  of  Midwifery.  With  246  Illustra 
tions.    Fourth  edition,  revised  and  enlarged.    8vo.     Cloth,  $5.00 ;  sheep,  $6.00. 

MARCY  (HENRY  0.).  The  Anatomy  and  Surgical  Treatment  of  Hernia. 
4to,  with  about  Sixty  full-page  Heliotype  and  Lithographic  Reproductions 
from  the  Old  Masters,  and  numerous  Illustrations  in  the  Text.  (Sold  only 
hy  siibscription.) 

MARKOE  (T.  M.).  A  Treatise  on  Diseases  of  the  Bones.  With  Illustrations. 
Svo.     Cloth,  $4.50. 

MATHEWS  (JOSEPH  M.).  A  Treatise  on  Diseases  of  the  Rectum,  Anus, 
and  Sigmoid  Flexure.  Svo.  With  Six  Chromolithographs,  and  Illustra- 
tions in  the  text.    Second  edition.     {Sold  only  "by  subscription.) 

MILLS  (WESLEY).  A  Text-Book  of  Animal  Physiology,  with  Introductory 
Chapters  on  General  Biology  and  a  full  Treatment  of  Reproduction  for 
Students  of  Human  and  Comparative  Medicine.  Svo.  With  505  Hlustra- 
tions.     Cloth,  $5.00;  sheep,  $6.00. 

MILLS  (WESLEY).  A  Text-Book  of  Comparative  Physiology.  For  Students 
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ROBINSON"  fA.  R.).  A  Manual  of  Dermatology.  Revised  and  corrected.  Svo. 
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VAN  BUREN  (W.  H.).  Lectures  upon  Diseases  of  the  Rectum,  and  the  Sur- 
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Second  edition,  revised  and  enlarged.    Svo.     Cloth,  $3.00 ;  sheep,  $4.00. 

VAN  BUREN  (W.  H.).  Lectures  on  the  Principles  and  Practice  of  Surgery. 
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VOGEL  (A.).  A  Practical  Treatise  on  the  Diseases  ot  Children.  Translated 
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WEBBER  (S.  G.).  A  Treatise  on  Nervous  Diseases :  Their  Symptoms  and 
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WELLS  (T.  SPENCER).    Diseases  of  the  Ovaries.     Svo.     Cloth,  $4.50. 

WORCESTER  (A.).     Monthly  Nursing.     Second  edition,  revised.     Cloth,  $1.25. 

WYETH  (JOHN  A.).  A  Text-Book  on  Surgery :  General,  Operative,  and  Me- 
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